• Informed Consent for Peptide Therapy

    Provider: Amber Tomse, APRNPractice: Beauty Refined, LLC
  •  - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Please read and understand each one:

    - Peptides are amino acids that have biological activity which mimic certain hormones within the body. Peptides have the ability of increasing certain naturally producing hormones within the body to illicit a certain effect which will be discussed by Amber Tomse, APRN. Certain peptides are FDA approved for the treatment of various diseases while other peptides are investigational new drugs that are not FDA approved to be marketed for consumption in humans even though clinical trials have shown them to have a favorable safety profile.

    -Peptide therapy for the purpose of preventative care, weight loss, performance enhancement, anti-aging, and any additional condition discussed by Amber Tomse, APRN is considered by the FDA to be “off-label use.”

    -Peptide therapy can be administered either orally, subcutaneously, intramuscularly, intravenously, or intranasally. The various preparations will be discussed with me by Amber Tomse, APRN.

    - Peptide therapies being administered by Amber Tomse, APRN D.B.A. Beauty Refined, LLC are prepared by registered compounding pharmacies that comply with all state and federal regulations.

    - I acknowledge that Amber Tomse, APRN D.B.A. Beauty Refined, LLC is not be responsible for any manufacturing issues related to peptides prepared by compounding pharmacies and that the sole responsibility for sterility, potency, and safety lie with these pharmacies.

    - I understand that peptide therapies are not necessarily approved for my medical conditions and they are not a medical necessity, rather, they are an adjunctive and complimentary therapy to my treatment plan. Therefore, I acknowledge that it is an elective treatment option.

    -(WOMEN ONLY) There has been little research regarding the safety of peptide therapy in pregnant and breast-feeding women. I certify that I am not pregnant nor plan on becoming pregnant while on peptide therapy.

    -I understand that with any drug, peptide therapies can carry potential side effects, including but not limited to:

    Rash, fever, nausea, vomiting, allergic reactions, decreased insulin sensitivity, flushing, headache, fatigue, lightheadedness, abdominal cramping, joint pain, fluid retention, and additional side effects not listed that will be discussed during your evaluation with Amber Tomse, APRN/Beauty Refined, LLC

    - I understand that alternatives to peptide therapy are:

             Doing nothing

             FDA approved standard medication treatments

             Referral to specialists.

             Surgery

    -I acknowledge that there are no guarantees relating to the efficacy of peptide therapies and that Amber Tomse, APRN D.B.A. Beauty Refined, LLC are not responsible for my individual performance and ability to also exercise and diet.

    - I certify that I will notify Amber Tomse, APRN D.B.A. Beauty Refined, LLC immediately if I have any concerns or side effects.

    - I certify that I have had the risks and benefits discussed with me about peptide therapy and that I have had all my questions and concerns answered to my satisfaction by Amber Tomse, APRN D.B.A. Beauty Refined, LLC

    - I hereby voluntarily consent to be evaluated and treated by Amber Tomse, APRN D.B.A. Beauty Refined, LLC with the goal of improving my health, performance, and possibly delaying the effects of aging through peptide therapies.

    -By making this purchase, Beauty Refined is not responsible for any lost or stolen packages.

    - All sales final, no refunds

  • Clear
  • prevnext( X )
                                                              AOD9604 - 500MCG30 days
                                                              $300.00
                                                                
                                                              CJC1295/Ipamorelin Injection8 weeks
                                                              $350.00
                                                                
                                                              PT-141 Injection
                                                              $255.00
                                                                
                                                              PT-14112 troche
                                                              $120.00
                                                                
                                                              Petadeca Arginate (BPC157) Injection30 days
                                                              $350.00
                                                                
                                                              Pentadeca Arginate Complex(BPC157) capsule500 mcg cap
                                                              $260.00
                                                                
                                                              Sermorelin Injection
                                                              $390.00
                                                                
                                                              GHK-Cu Injectioncooper tripeptide- Reconstitute with 6mL bacteriostatic water inject 20 units (0.2mL) SQ daily.
                                                              $375.00
                                                                
                                                              Glutathione10ml vial
                                                              $150.00
                                                                
                                                              MIC/B12 10ml10 weeks
                                                              $150.00
                                                                
                                                              Lipotropic Super B: Methionine / Inositol / Choline / L-Carnitine / Dexpanthenol / B12 (methylcobalamin) / Niacin / Lidocaine / Pyridoxal 5-Phosphate / Riboflavin / Thiamine10ml- 10 weeks
                                                              $200.00
                                                                
                                                              IGF-1 LR3 Injection Solution100mcg/ml -6.2ml vial inject 0.4-0.8ml sq once daily for 30-60 days on 30d off
                                                              $300.00
                                                                
                                                              Tesamorelin Injection30 days
                                                              $600.00
                                                                
                                                              5-amino-1mq90 capsules TAKE ONE CAPSULE BY MOUTH THREE TIMES PER DAY.
                                                              $500.00
                                                                
                                                              Pinealon4mg/mL 5mL (20mg) Vial Pre-mixed Injectable- would take the vial for 20 days then repeat the protocol every 4-6 months.
                                                              $550.00
                                                                
                                                              TB-5004-week protocol 2 vials: Reconstitution is with 4mL's of BAC water. Inject 50 units (0.50mL) 1 vial: Reconstitution is with 4 mL's BAC water. Inject 50 units (0.50mL) 1.87 mg 2x per week
                                                              $300.00
                                                                
                                                              NAD+ Troches30 tabs
                                                              $200.00
                                                                
                                                              NAD+1000mg vial -INJECT 50 UNITS (100MG) SQ or IM 2-3 TIMES PER WEEK
                                                              $350.00
                                                                
                                                              Methylene Blue Capsules10mg- 30 day supply
                                                              $75.00
                                                                
                                                              Thymulin 15mg-Reconstitute with 3mL's BAC water. Inject 10 units (0.10mL) SQ daily.
                                                              $290.00
                                                                
                                                              VITAMIN C/VITAMIN D3/ZINC VEGI-CAP CAPSULES 1000MG/5000IU/25MG 30 capsules - take with thymulin or by itself
                                                              $30.00
                                                                
                                                              Hexarelin Injection500mcg/ml 5ML vial
                                                              $170.00
                                                                
                                                              CB4211 the new MOTS-C10mg SQ 2x per week. Mondays and Thursdays- 1 month supply
                                                              $440.00
                                                                
                                                              SS-31 Injection (Elamipretide)300mg vial- Inject 20 units (0.2mL) SQ daily - 1 month supply
                                                              $590.00
                                                                
                                                              Macimorelin30 days
                                                              $180.00
                                                                
                                                              Ivermectin
                                                              $2.00
                                                              Capsule Quantity Price
                                                              3mg $2.00
                                                              6mg $2.50
                                                              12mg $3.00
                                                              18mg $5.00
                                                                
                                                              SLU-PP-332 30 days
                                                              $190.00
                                                              Quantity Price
                                                              30 days $190.00
                                                              90 days $420.00
                                                                
                                                              Semax7.5mg/mL6mLNasal Spray
                                                              $200.00
                                                                
                                                              SELANK7.5mg/ml6mLNasal Spray
                                                              $200.00
                                                                
                                                              coupon loading
                                                              Subtotal
                                                              $0.00
                                                              Tax
                                                              $0.00
                                                              Shipping
                                                              $0.00
                                                              Total
                                                              $0.00

                                                              Credit Card
                                                              Billing Address
                                                            • Should be Empty: