Telemedicine Patient Intake Form

Please, indicate your goals for this therapy

The nature of the procedure and/or treatment described below has been explained to me, and I have consented to treatment by Revive With Me, its affiliated professional entities and its staff. I understand that just as there may be benefits from the procedure, all procedures involve risk to some degree.

The purpose of this form is to provide written information regarding the risks, benefits and alternatives of the treatments named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form. YOU MUST BE 18 YEARS OR OLDER TO RECEIVE THIS TREATMENT.

Peptides are small chains of amino acids that can have biological activity. Some peptides are FDA approved for the treatment of certain diseases. Other peptides used clinically are prepared by duly registered compounding pharmacies that comply with all state and federal laws. Peptides can be administered in various presentations, including but not limited to oral, intravenous, subcutaneous, intramuscular, and intranasal routes. Understanding this, I hereby acknowledge and consent to the following:

Peptides are short chains of amino acids that can stimulate various biological processes in the body. The purpose of this treatment is to enhance recovery, lose weight, promote anti-aging, aid in muscle growth, etc..

Peptide treatment involves injection or injestion, and the specific peptide(s) used in this treatment is/are including but not limited to, semaglutide, tirzepatide, igf1, BPC157, SS31, GHK-CU, TB500, MOTS C, CJC/Ipamorelin, as well as other vitamins and aminos . The expected duration of treatment is 8 weeks with up to daily applications.

While peptides are generally well-tolerated, there are possible side effects, including but not limited to:Redness, swelling, or pain at the injection siteHeadachesFatigueDizzinessNauseaAllergic reactionsHormonal imbalances (depending on the peptide used)Please consult your practitioner immediately if you experience any adverse effects or have concerns about the treatment.

The potential benefits of peptide treatment include, but are not limited to:Improved muscle recovery and growthEnhanced skin elasticity and reduced signs of agingIncreased energy and vitalityBetter sleep qualitySupport for weight managementResults may vary based on individual response.

Alternative treatments or therapies are available, including exercise, diet, and weight training. You are encouraged to discuss these alternatives with your practitioner. I understand that the use of this peptides is not necessarily approved for my medical conditions and that my provider is providing this, following the principles of the practice of medicine and the laws regulating compounding pharmacies, as a complement to my current treatments. As with any other drug, peptide therapies can have side effects, including but not limited to:NauseaVomitingFeverInjection site reactions (pain, rash, bleeding)Allergies, including life threatening allergiesAdditional side effects not listed may also occurI understand that alternatives to peptide therapy are:Do nothing.Other medication useSurgery or other therapeutic interventionExercise and lifestyle modification

I acknowledge that:I have read and fully understood the information provided about peptide treatment.I have had the opportunity to ask questions regarding the treatment, and those questions have been answered to my satisfaction.I understand the potential risks and benefits involved and consent to the administration of the treatment.

I understand that peptide therapy is a voluntary treatment and that I may refuse or discontinue it at any time without penalty. I hereby give my informed consent for the administration of peptide treatment. I furthermore understand that Peptide therapy is being used as part of an integrative treatment approach. Having read this, I hereby acknowledge that I am voluntarily undergoing peptide therapy and that I hereby relieve Revive With Me of any legal responsibility regarding side effects or complications that may occur due to receiving peptide therapies. I certify that if any concerns or side effects occur, I will promptly notify an Revive With Me provider. I also understand that Revive With Me is not responsible for any manufacturing issues related to these peptides, such as sterility and potency, which are the sole responsibility of the compounding pharmacy preparing them.This is my consent including any medical provider or consultant who works with the company, to begin treatment for Peptide Therapy with my consent if it is in my agreed upon treatment plan.It has been explained to me, and I fully understand, that occasionally there are complications with this treatment.Extra fluid in the body – This can potentially cause problems for patients with heart, kidney, or liver disease.I understand that I may be asked to get blood work.I understand there is no guarantee as to the result and that if I stop treatment, my condition may return or get worse.I have had an opportunity to discuss my complete past medical and health history including any serious problems and/or injuries. All my questions concerning the risks, benefits and alternatives have been answered. I am satisfied with the answers.I understand that the physical exam does not replace a full physical exam by a personal physician.I agree that, while a patient, I will not take any type of anabolic steroids, testosterone gels, hormone boosters, pro-hormones or any additional testosterone supplementation not provided by Revive With Me during my treatment plan. I understand that at any time, if use of these items is discovered, I will be discharged as a patient.

Acknowledgment of Training:Self Injection ConsentRevive with Me has provided me with the information concerning self-injectionsThe injections expire on the expiration date printed on the label and I will not be refunded for any unused injectionsBy taking the injections home I cannot bring back any of the injections for any reasonTo throw away injection in a regular garbage can is illegal. I can throw the injections away in a closed container or buy a bio-hazard container.Injections need to be kept away from childrenI have received the “Giving Self Injections” sheet and the staff at the clinic has answered all of my questions regarding self-injections.Because my injections are given at home, Revive with Me is not liable for any consequences that may come from giving me an injection at home.

AGE, PREGNANCY, ALLERGIES & NEUROLOGIC DISEASE. I am at least 18 years of age or older.I am not aware that I am pregnant, and I am not trying to get pregnant.I am not lactating (nursing).I do not have liver or kidney dysfunction.I do not have Lieber’s disease.I do not have Atrophic Gastritis.I do not have an allergy to cobalt, vitamins, food dye or preservatives.Certain herbal products, vitamins, minerals, nutritional supplements, prescription, and non-prescription medications may result in side effects when they interact with peptide Injections.This treatment should not be taken if you are pregnant, nursing or attempting pregnancy. People with chronic liver and/or kidney dysfunction should not take frequent peptide injections. B12 is contraindicated for in Leber’s disease – a hereditary optic nerve atrophic condition and Atrophic Gastritis. This treatment should not be taken if you have an allergy to Cobalt, vitamin, food dye or preservative. 

Anti-diabetic agents, specifically: Insulin and Sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® (THIS IS NOT AN ALL-INCLUSIVE LIST). Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.

Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease.

common injection site reactions characterized by itching, burning at site of administration with or without thickening of the skin(welting). If you notice other side effects not listed above, contact your doctor or pharmacist.

A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing. Report adverse side effects to your doctor or pharmacist. In the event of any emergency, call 911 immediately.

I understand this is an elective procedure and/or treatment, and I have voluntarily consented to treatment. The procedure and/or treatment has been fully explained to me, and I understand that I have the right to discontinue treatment at any time. I understand there are other alternatives to the procedures and/or treatments that I have volunteered for, and acknowledge that no guarantees have been made to me concerning my results. I have informed the medical staff of any known allergies to drugs or other substances, and any past adverse reactions I have experienced. I have informed the medical staff of all medications and supplements I am currently taking. I am aware of possible side effects and drug interactions, and if I am prescribed medication by Revive With Me, I understand that I must read and understand any disclosures included with that medication before using it. By signing below, I certify that I have read and understand the contents of this form.