Client Medical History & Self-Administration Consent & Release Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

E-mail*

Phone Number

Area CodePhone Number

Date of Birth*

DayMonthYear

How did you hear about us?

Height

Weight

Weight Loss Goal *if applicable (# of lbs)

1) Have you ever been diagnosed with medullary thyroid disease/cancer?*

YesNo

Please provide details

2) Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?*

YesNo

Please provide details

3) Have you ever been diagnosed with pancreatitis?*

YesNo

Please provide details

4) Are you pregnant, breastfeeding or plan to become pregnant soon?*

YesNo

Please provide details

5) Have you ever been diagnosed with gastroparesis?*

YesNo

Please provide details

6) Have you ever been diagnosed with kidney impairment or disease?*

YesNo

Please provide details

7) Have you ever been diagnosed with Multiple Endocrine Neoplasia type 2?*

YesNo

Please provide details

8) Have you ever been diagnosed with diabetes?*

YesNo

Please provide details

9) Do you have a history of gallstones or gallbladder disease?*

YesNo

10) Have you ever been diagnosed with an eating disorder or have struggled with disordered eating?*

YesNo

If yes, please provide details (time period, treatment history)

11) Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?*

YesNo

Please provide details

12) Are you currently taking any medications? If yes, please list below.*

YesNo

Please provide details

SIGNATURE ATTESTATION
Confirmation of Accuracy and Acknowledgment of Risks

I, the undersigned, hereby attest that the information I have provided in the attached Medical Assessment Form is complete, truthful, and accurate to the best of my knowledge. I understand that the accuracy of this information is critical for my care and treatment.

I acknowledge the following:

Responsibility for Accuracy: I understand that providing false, incomplete, or misleading information could affect my diagnosis, treatment, and the quality of care I receive.Potential Risks: I recognize that inaccuracies or omissions in my medical history, medications, allergies, or symptoms may result in improper treatment plans, adverse drug interactions, misdiagnosis, or other negative health outcomes.Obligation to Update Information: I understand that I must immediately inform my healthcare provider of any changes or new information regarding my health status, medical history, or any other relevant details.I certify that I have filled out this form to the best of my ability and accept full responsibility for the information I have provided.

Signature

PEPTIDE SELF-ADMINISTRATION CONSENT & RELEASE

This Agreement is entered into by the undersigned purchaser (hereinafter referred to as "Buyer") and Elevation Health and Premium Peptides (hereinafter referred to as "Seller") regarding the purchase of peptides.

Introduction
I, the undersigned, hereby acknowledge that I have elected to self-administer peptide therapy. I understand that peptides are classified as investigational or off-label treatments and may not be approved by the FDA for all uses.

1. Acknowledgment of Risks
The Buyer acknowledges that the use of peptides may have potential risks, including, but not limited to, health risks, allergic reactions, and other adverse effects. The Buyer is aware that peptides are intended for research or other lawful uses as permitted by applicable laws and regulations. The Buyer is solely responsible for ensuring the legality of the peptides in their jurisdiction.

2. Medical Disclaimer
The Buyer understands that Seller is not a Physician, does not provide medical advice, and the Seller is not responsible for any consequences arising from the Buyer’s use of peptides.

3. Instructions & Self-Administration
I confirm that I have been instructed by a qualified provider on how to properly store, prepare, and administer the peptide(s); informed of the proper technique for subcutaneous or intramuscular injection (if applicable), advised to immediately report any signs of infection, adverse reaction, or unexpected side effects.
I understand that I am solely responsible for following the administration protocol and safety precautions as instructed.

4. Risks & Side Effects
I understand that potential risks and side effects of peptide therapy may include but are not limited to:

Injection site reactions (redness, swelling, pain)
Headache, dizziness, nausea
Allergic reactions
Hormonal imbalance or unexpected metabolic effects

I acknowledge that these risks may be heightened if peptides are not properly administered or if contraindicated by existing health conditions.

5. Release of Liability
To the fullest extent permitted by law, the Buyer hereby releases, discharges, and holds harmless the Seller, its owners, employees, agents, and representatives from any and all liability, claims, damages, or injuries, including but not limited to personal injury, illness, death, property damage, or other harm, resulting directly or indirectly from the purchase, use, or misuse of the peptides sold under this agreement.

6. Indemnification
The Buyer agrees to indemnify and hold harmless the Seller from any and all claims, actions, demands, costs, or expenses (including attorney’s fees) arising from the Buyer’s use, sale, or distribution of peptides.

7. Legal Compliance
The Buyer agrees to comply with all applicable local, state, and federal laws, regulations, and guidelines regarding the possession, use, and sale of peptides. The Seller assumes no responsibility for any legal consequences resulting from the Buyer’s actions.

8. Binding Agreement
By signing this waiver, the Buyer agrees to be bound by its terms and acknowledges that they have read, understood, and voluntarily accepts the contents of this agreement.

9. Governing Law
This waiver and release shall be governed by and construed in accordance with the laws of the jurisdiction in which the Seller is based.

10. Acknowledgment & Consent
I certify that I:
-Have read and fully understand this consent and release form
-Have had the risks, benefits, and procedures explained to me
-Am competent to provide consent and do so voluntarily

Signature