I authorize Evolus Wellness to evaluate and treat me with hormone replacement therapy and/or peptide therapy as determined appropriate by my provider. This consent covers testosterone therapy and related hormone treatment, as well as peptide therapies including but not limited to CJC-1295, Ipamorelin, BPC-157, TB-500, MOTS-c, AOD-9604, GHK-Cu, Thymosin Alpha-1, and similar products used in wellness care.

I understand that testosterone is a Schedule III controlled substance and is subject to prescribing, monitoring, refill, and diversion-control rules.  I further understand that many peptide therapies are not FDA-approved for the intended use, may be compounded, and may have limited human safety and efficacy data.

Nature of treatment

Hormone therapy may be recommended for symptoms or diagnoses related to hormone deficiency, imbalance, or optimization. Peptide therapy may be used for recovery, body composition, metabolism, sleep, inflammation, tissue support, or related wellness goals.  Some therapies may be prescribed off label. Compounded medications are generally not reviewed by FDA for safety, effectiveness, or quality before marketing.

Voluntary consent

My participation is voluntary. I may refuse treatment, stop treatment, or withdraw consent at any time by notifying Evolus Wellness.  I understand that stopping treatment may result in return of symptoms or loss of expected benefit, and no guarantee of outcome has been made.

Benefits and alternatives

Potential benefits may include improvement in energy, libido, mood, body composition, sexual function, recovery, sleep, or other symptoms depending on the treatment selected.

Alternatives include no treatment, lifestyle changes, sleep optimization, nutrition, weight management, treatment of underlying medical conditions, fertility-preserving options, and other therapies recommended by my provider.

Risks and side effects

I understand that hormone therapy, including testosterone, may cause acne, oily skin, hair loss, increased body hair, mood changes, irritability, swelling, headaches, blood pressure changes, testicular shrinkage, lower sperm production, infertility, polycythemia, worsening sleep apnea, urinary or prostate symptoms, cardiovascular complications, liver abnormalities, lipid changes, and injection-site reactions.

I understand that peptide therapy may cause injection-site reactions, allergic reactions, contamination or impurity risk, headache, dizziness, nausea, flushing, palpitations, fatigue, appetite changes, water retention, blood sugar changes, hormonal effects, and unknown long-term risks due to limited data.

I understand that FDA has identified safety or insufficient-safety concerns for several peptides commonly used in wellness practice, including BPC-157, CJC-1295, Ipamorelin, MOTS-c, injectable GHK-Cu, AOD-9604, and thymosin-related products.

Controlled substance and medication safety

I agree to use testosterone only as prescribed and not to share, sell, loan, transfer, or misuse any prescribed medication.  I agree not to change dose, route, or frequency without provider approval. Lost, stolen, damaged, or destroyed medication may not be replaced.

I agree not to share any hormone, peptide, injectable, or compounded medication with any other person.  If I receive medication for home use, I am responsible for proper storage, refrigeration if required, sterile technique if applicable, child-safe storage, and safe handling of needles, syringes, and supplies.

Monitoring and follow-up

I understand that ongoing monitoring is required and may include office visits, telehealth visits, lab testing, blood pressure checks, symptom review, and pharmacy review.  Monitoring may include testosterone levels, CBC, hematocrit, liver tests, lipids, PSA, metabolic markers, and other tests selected by my provider.  Failure to complete follow-up or requested laboratory testing may result in delayed treatment, refusal of refill, dose changes, or discontinuation of therapy.

Telehealth and disposal

If any part of my care is provided by telehealth, I consent to telehealth care and understand that Evolus Wellness may require in-person follow-up when clinically or legally necessary.

I agree to follow Evolus Wellness instructions for disposal of unused, expired, contaminated, or compromised medications and sharps, and I will not transfer unused medication to another person.

Patient acknowledgments

I confirm that I have disclosed my medical history, medications, supplements, allergies, pregnancy or breastfeeding status, fertility goals, and any history of cancer, prostate disease, sleep apnea, clotting disorder, heart disease, liver disease, kidney disease, endocrine disease, autoimmune disease, psychiatric illness, substance misuse, anabolic steroid misuse, or adverse reaction to compounded medications.

I understand the known, potential, and unknown risks of hormone and peptide therapy. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction.

I understand that Evolus Wellness may decline, modify, or stop treatment if medically indicated, legally required, or operationally necessary.

Signatures

By signing below, I give my informed and voluntary consent to hormone replacement therapy and/or peptide therapy through Evolus Wellness.

Compounded Semaglutide and Tirzepatide

Evolus Wellness 3626 N Hall St, Dallas, TX 75219 | 469.999.1512

This consent covers treatment with compounded GLP-1 medications, including compounded semaglutide and/or compounded tirzepatide, prescribed or managed by Evolus Wellness for weight management, metabolic health, or other indications determined by my provider. I understand that results are not guaranteed and that lifestyle changes, monitoring, and other treatments may still be required.

Voluntary consent

My participation is entirely voluntary. I may refuse treatment, stop treatment, or decline future treatment at any time by notifying Evolus Wellness. No one has pressured me to begin GLP-1 therapy.

Regulatory status

I understand that compounded semaglutide and compounded tirzepatide are not FDA-approved finished drug products, and FDA does not review compounded drugs for safety, effectiveness, or quality before they are marketed.

I understand compounded drugs should generally be used only when a patient’s medical need cannot be met by an FDA-approved drug or when the FDA-approved drug is not commercially available.

I understand FDA has clarified that semaglutide and tirzepatide do not currently appear on the 503B bulks list or the FDA drug shortage list, and compounding of products that are essentially copies of commercially available drugs is legally restricted unless a prescriber documents a significant difference for an identified individual patient.

Nature of treatment

GLP-1 therapy may help with appetite control, blood sugar regulation, insulin resistance, and weight reduction. I understand treatment may involve dose titration over time and may be stopped, delayed, or adjusted depending on side effects, lab results, supply, or medical appropriateness.

 Risks and side effects

I understand that semaglutide and tirzepatide may cause nausea, vomiting, diarrhea, constipation, abdominal pain, decreased appetite, reflux, bloating, fatigue, dizziness, dehydration, and injection-site reactions. Serious or potentially serious risks may include pancreatitis, gallbladder problems, severe gastrointestinal symptoms, kidney injury from dehydration, allergic reaction, worsening diabetic retinopathy in susceptible patients, and possible need for emergency medical care.

I understand FDA has received adverse event reports associated with compounded semaglutide and compounded tirzepatide, including serious events, and that dosing errors have occurred when patients or providers miscalculate doses or increase doses too quickly.

I understand there may be additional risks from compounded products, including potency variation, contamination, shipping temperature problems, labeling problems, fraudulent products, or use of unlawful ingredients such as semaglutide salt forms.

Dosing and administration safety

I agree to use the medication only as prescribed and not to increase the dose, take doses more frequently, or change the titration schedule without provider approval. I understand that compounded GLP-1 products may require careful measuring and self-injection technique, and I agree to ask questions if I am unsure how to prepare or administer a dose.

If the medication arrives warm, appears mislabeled, appears tampered with, or seems inconsistent with what I was prescribed, I will not use it until I contact the pharmacy or Evolus Wellness.

Monitoring and follow-up

I understand that ongoing monitoring is required and may include office visits, telehealth visits, weight checks, symptom review, blood pressure checks, lab testing, and medication review. Failure to complete recommended follow-up may result in delayed treatment, refusal of refill, dose changes, or discontinuation of therapy.

Source, storage, and disposal

I understand I should obtain my medication only from a state-licensed pharmacy pursuant to a valid prescription. I will not purchase semaglutide, tirzepatide, or similar products marketed as research-use, not-for-human-consumption, counterfeit, or from unauthorized online sellers.

I understand injectable GLP-1 products typically require refrigeration and proper storage. I agree to follow pharmacy and clinic instructions for storage, handling, sharps disposal, and disposal of unused or compromised medication. I will not share medication with any other person.

Telehealth consent

If any part of my care is delivered by telehealth, I consent to telehealth services and understand that Evolus Wellness may still require in-person evaluation, labs, or follow-up when clinically or legally necessary.

Patient acknowledgments

I confirm that I have disclosed my medical history, current medications, allergies, pregnancy or breastfeeding status, prior pancreatitis, gallbladder disease, kidney disease, gastrointestinal disorders, diabetes history, and other relevant conditions.

I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I understand the purpose, risks, limitations, and regulatory status of compounded semaglutide and tirzepatide. I understand Evolus Wellness may decline, modify, or stop treatment if medically indicated, legally required, or operationally necessary.

By signing below, I give my informed and voluntary consent to receive compounded GLP-1 therapy through Evolus Wellness and agree to follow the above instructions.

Evolus Wellness 3626 N Hall St, Dallas, TX 75219 | 469.999.1512

I authorize Evolus Wellness to evaluate and treat me with intranasal ketamine therapy, a Schedule III controlled substance, off-label for conditions such as treatment-resistant depression, anxiety, PTSD, chronic pain, or other indications determined by my provider. I understand results are not guaranteed and other treatments may still be required.

Voluntary consent

My participation is entirely voluntary. I may refuse treatment, stop a session at any time, or decline future treatments without penalty or loss of other appropriate care. No one has pressured me to receive ketamine therapy.

Nature, risks, and side effects

I understand that ketamine is a Schedule III controlled substance with potential for psychological and physical dependence, and misuse or dose escalation outside protocol increases this risk.

I understand that intranasal ketamine can cause:

• Dissociation, altered perception, confusion, and changes in time or space perception.
• Dizziness, lightheadedness, blurred vision, and increased risk of falls.
• Nausea, vomiting, headache, and nasal irritation.
• Increased blood pressure and heart rate, and possible arrhythmias in patients with heart disease.
• Anxiety, agitation, panic, or worsening psychiatric symptoms.
• Rare but serious risks including bladder problems with frequent or long-term use, liver enzyme elevation, respiratory depression, especially with other sedating drugs, and allergic reactions including anaphylaxis.

I understand there may be risks that are unknown or not fully characterized.

Conditions and contraindications

I have disclosed my full medical history and current medications. I understand ketamine may be unsafe or inappropriate if I have uncontrolled high blood pressure, serious heart disease, history of psychosis or mania, recent substance use disorder, pregnancy or breastfeeding, elevated intracranial pressure, prior stroke, or use of certain interacting medications. I will promptly report any new diagnoses, medications, or substance use.

Safety protocols

I agree to follow Evolus Wellness safety rules:

• A qualified staff member will be present during administration and observation.
• The ketamine nasal device will be controlled by staff and taken back immediately after use; I will not take the bottle or any ketamine home.
• I will remain seated or in a supervised position for at least 15 minutes, or longer if instructed, and will not stand or walk without staff approval.
• My vital signs, including blood pressure and heart rate, may be checked before, during, and after treatment. Sessions may be delayed, changed, or stopped for safety.
• I will not drive, operate heavy machinery, or make important decisions for the remainder of the day after treatment and will arrange a safe ride home.

Controlled substance and authorization

I understand ketamine is a controlled substance subject to strict storage and documentation rules. I:

• Authorize Evolus Wellness and its licensed personnel to receive, store, and manage my ketamine prescription in a locked, compliant manner for in-clinic use.
• Will not seek additional ketamine or ketamine-containing products from other providers without disclosing this treatment.
• Will not attempt to obtain, possess, or use ketamine outside of this supervised clinical setting.

Disposal, privacy, and telehealth

I understand that any unused ketamine or remaining doses will be disposed of by Evolus Wellness staff in accordance with state and federal controlled-substance disposal rules, and I will not request unused medication or empty devices.

My treatment records are protected by privacy laws, and ketamine prescribing may be reported to state prescription monitoring systems as required by law. I understand intranasal ketamine is often not covered by insurance and I am responsible for payment for services received.

If any part of my care is delivered by telehealth, such as intake or follow-up visits, I consent to telehealth services and understand that Evolus Wellness may still require in-person evaluation or monitoring to comply with controlled-substance and safety requirements.

Patient acknowledgments

I attest that:

• I have read or had this form read to me and had the chance to ask questions.
• My questions have been answered to my satisfaction.
• I understand the purpose, risks, safety requirements, and alternatives.
• I understand I can stop treatment at any time and that the clinic may stop treatment if medically or legally necessary.

By signing below, I give my informed and voluntary consent to receive intranasal ketamine therapy at Evolus Wellness and agree to follow the above rules and instructions.

1. The importance of a low fat, whole food diet that includes at least 1500 calories per day and the inclusion of fruits, vegetables, and whole grains if tolerated.
2. Patient instructed to set a goal of 150 min of mild to moderate cardiovascular exercise per week if tolerated.
3. If you miss a dose, take the dose as soon as you remember, unless it's almost time for your next scheduled dose.
4. Be aware of potential side effects such as nausea, diarrhea, constipation or hypoglycemia, and seek medical attention if you experience severe symptoms.
5. Follow a healthy diet and exercise regimen as recommended by your healthcare provider to maximize the benefits of the medication.
6. Increasing water intake to at least 64 ounces daily, as well as consuming healthy fiber to maintain regular bowel function are important. Over-the-counter fiber capsules can be added if needed.
7. Take a gradual and incremental approach towards their goal, aiming for a short-term weight loss of 5 to 10 percent, equivalent to 1 to 2 pounds per week.
8. Remember to always consult your healthcare provider for personalized advice regarding the use of GLP-1.