Peptide Therapy Registration & Consent

Peptide Therapy Registration & Consent

Forum Health Denver (Formerly RevolutionaryMD)
Today's Date*

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Full Name*

First NameLast Name
Birth Date*

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Weight | Height (Estimated)*
Address*

Street Address

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Patient Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Employer*
Occupation*
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How did you hear about us?*
What goals are you seeking to achieve through Peptide Therapy?*
Have you tried peptide therapy in the past?*
Emergency Contact*

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Financial Policy Agreement
ALL PATIENTS NEW TO PEPTIDE THERAPY ARE REQUIRED TO COMPLETE AN IN-PERSON CONSULTATION WITH A REVOLUTIONARY MD NURSE PRIOR TO TREATMENT:
- Initial consultation can be done in person or via ZOOM/phone call
- This weight loss program fee is $395 and includes all follow-up coaching with our nurse for 6-months
- Your peptide of choice is purchased separately
- If you require peptides to be mailed to your address, you are financially responsible for any and all shipping costs. In the event FedEx overnight delivery is late and your peptides go bad, we are not financially responsible for the lost product.
- We accept cash, checks, MasterCard, and Visa
- This therapy is not covered by insurance, but you may be able to use a health saving account to cover this.
- Patients are responsible payment after completing patient visit on day of service.
- Appointments cancelled less than 24 hours prior to a scheduled time may be subject to a $50 cancellation fee
By signing below, you confirm that you have read and agree to the policies presented above.
Patient Signature*
Today's Date*

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Date

Peptide Therapy Informed Consent
I am executing this consent to conﬁrm my decision to purchase peptides and to verify my understanding of the risks and alternatives to treatment with peptide therapy.

The goals and possible beneﬁts of this therapy are to try and prevent, reduce or control the dysfunction associated with the aging process, through hormonal balancing, control of oxidative stress, and stimulating the body's own innate repair systems. However, I understand that this treatment may be viewed by the mainstream medical community as new, controversial, and unnecessary by the Food and Drug Administration (FDA).
Risks:

At prescribed doses, there are not expected to be any significant risks/adverse reactions as long as full medical disclosure is achieved from the patient during the total time of therapy.

Some adverse reactions may include but are not limited to injection site redness, ﬂushing, transient high blood sugar, development of antibodies peptides, and water retention. These side effects are dose-related and usually eliminated by adjusting the dosage. This drug should not be used in patients with known cancer or are pregnant.

By signing this form, I understand the possible risks associated with this treatment.

I understand that Dr. Grover and his medical staff will monitor my treatment in an effort to manage any side effects, but cannot guarantee that I will not experience any side effects or adverse reactions.

I understand that, as with any health treatment, there is no guarantee I will obtain satisfactory results through the use of this therapy.

I certify that I have read the foregoing Informed Consent, discussed the issues noted above, had opportunities to ask questions and agree and accept all of the terms above.
Patient Signature*
Today's Date*

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Provider Signature (Patients: Leave Blank)
We welcome you to Forum Health Denver!
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Peptide Therapy Registration & Consent

Health Information Questionnaire

Financial Policy Agreement

By signing below, you confirm that you have read and agree to the policies presented above.

Peptide Therapy Informed Consent