NAD+ & Peptide Therapy Consent Form

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Full Name* This field is required.
First Name
Last Name
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Gender* This field is required.
Male
Female
Other
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Date of Birth* This field is required.
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Where Are You Located?* This field is required.
City
State
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Phone Number* This field is required.
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Email* This field is required.
example@example.com
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NAD+ and Peptide Therapy

These are are advanced treatments designed to support cellular repair, energy metabolism, hormonal balance, and healthy aging. These therapies are offered as part of a personalized wellness plan under the supervision of a licensed provider.

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Purpose of Treatment

NAD+ (Nicotinamide Adenine Dinucleotide) therapy helps restore mitochondrial function, improve energy levels, and enhance DNA repair. Peptides such as Sermorelin and GHRP-2 stimulate the natural production of growth hormone, promoting recovery, sleep, body composition, and cognitive function.
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Kindly review the following and select any items that are applicable to your current health status.* This field is required.
I am at least 18 years old and interested in anti-aging or performance-based wellness.
I have disclosed my full medical history, including any hormone-sensitive conditions, thyroid disorders, or chronic illnesses.
I understand that NAD+ and peptide therapies are not FDA-approved for anti-aging but are supported by clinical evidence.
I understand these therapies may be prescribed based on symptoms and clinical judgment even if lab values fall within the reference range
I agree to notify my provider of any new symptoms or adverse reactions during therapy.
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Please review the following conditions and check any that apply to your current health status, as they may impact treatment eligibility.* This field is required.
Fatigue or low energy levels
Brain fog or memory issues
Low libido or sexual performance issues
Weight gain, especially around the abdomen
Loss of muscle mass or strength
Slow healing or recovery after workouts
Chronic stress or mood swings
Low motivation or productivity
Interest in healthy aging or performance optimization
None of These
Other
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Please review the following conditions and check any that apply to your medical history, as they may impact treatment eligibility.* This field is required.
History of cancer (especially hormone-sensitive cancers)
Liver or kidney disease
Cardiovascular disease or high blood pressure
Psychiatric conditions (e.g., depression, bipolar, schizophrenia)
Autoimmune disease
Currently taking prescription medications
Allergies to any components of NAD+ or peptides
None of These
Other
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I understand that a licensed medical provider will review my intake form and medical history to determine if this therapy is appropriate for me. No medication will be prescribed without clinical justification and professional medical judgment.
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Potential Risks and Side Effects

Possible side effects of NAD+ therapy include flushing, nausea, cramping, or fatigue. Peptide therapy may cause injection site reactions, fluid retention, joint pain, changes in blood sugar, or temporary tingling or numbness. Most side effects are mild and resolve with dose adjustments.

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Monitoring and Follow-Up

I agree to participate in periodic follow-up visits and/or lab testing to assess my response to therapy. I understand that adjustments may be made to ensure the safest and most effective outcome.
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Please read and acknowledge the following disclosures to ensure informed consent and compliance with medical and legal standards.* This field is required.
I acknowledge that this treatment may include off-label or compounded formulations.
I consent to receive therapy via telehealth and understand that all evaluations and recommendations comply with state law.
I understand that Koreme Anti-aging & Aesthetics Group and its providers are not liable for adverse reactions due to undisclosed history, misuse, or noncompliance.
I understand that I may stop therapy at any time and that doing so will not affect my right to receive future care.
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Consent for Treatment

I have read and understand this consent form. I have had the opportunity to ask questions, and all of my questions have been answered. I voluntarily consent to begin NAD+ and peptide therapy under the supervision of a licensed healthcare provider.
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Signature* This field is required.Please sign below to confirm that the information provided is accurate and that you have read and understood the above acknowledgments.
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