NEXAROUSE™ - Mood Enhanced Erectile Function Supplement
Ketamine 15 mg, Apomorphine 2 mg, Sildenafil 50 mg, Oxytocin 50 units (patent pending)
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NEXAROUSE™ — Patient Consent and Acknowledgment FormPurpose:NexArouse™ is a compounded sublingual formulation designed to enhance mood-related sexual function through the combined effects of ketamine, oxytocin, apomorphine, and sildenafil. The goal is to address erectile or arousal difficulties that are influenced by psychological, mood, or stress-related factors.1. Description and MechanismKetamine acts on NMDA receptors and modulates glutamate pathways to improve mood and relieve anxiety.Oxytocin enhances bonding, connection, and emotional intimacy.Apomorphine activates dopamine receptors, supporting arousal and motivation.Sildenafil improves blood flow to the genital tissues to facilitate erection.This medication is compounded for individual use and is not FDA-approved as a combination.2. Method of AdministrationPlace one tablet under the tongue and allow it to fully dissolve.Do not chew or swallow the tablet whole.Onset typically occurs within 15–30 minutes, with duration of effects lasting 1–3 hours.3. Potential BenefitsImproved sexual confidence and arousal.Reduction in performance anxiety or mood-related sexual dysfunction.Enhanced mood, connection, and overall sexual experience.4. Possible Side EffectsCommon side effects may include:Mild dizziness or lightheadednessNauseaFacial flushing or nasal congestionHeadacheTemporary increase in heart rate or blood pressureSedation or disorientation (rare)Seek immediate medical attention if you experience chest pain, prolonged erection (lasting more than 4 hours), severe dizziness, or visual changes.5. Precautions and RestrictionsDo not drive, operate heavy machinery, or engage in hazardous activities for at least 2 hours after taking NexArouse™.Do not combine with alcohol, benzodiazepines, opioids, or other sedatives.Avoid taking with nitrates, recreational “poppers,” or other PDE5 inhibitors.Use only as prescribed by your physician.This product is intended for on-demand use and not for daily administration unless specifically directed.6. AcknowledgmentBy signing below, I acknowledge that:I have been informed of the purpose, potential benefits, and possible side effects of NexArouse™.I understand that the formulation is compounded and not approved by the FDA as a combined product.I understand and agree not to drive or operate machinery for at least two (2) hours after taking a dose.I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.I voluntarily consent to the use of NexArouse™ as part of my individualized treatment plan.
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Cardiovascular HealthDo you have a history of heart attack (myocardial infarction)f or stroke?Have you ever been diagnosed with congestive heart failure (CHF) or a low ejection fraction?Do you currently experience chest pain, shortness of breath, or palpitations with exertion?Have you ever been diagnosed with arrhythmia such as atrial fibrillation, valvular disease, or uncontrolled hypertension?Do you currently take nitrate medications (e.g., nitroglycerin, isosorbide mononitrate)?Have you had a stroke or transient ischemic attack (TIA) in the past?Have you ever fainted or felt dizzy after taking erectile dysfunction medications (Viagra, Cialis, etc.)?
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Yes
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Have you ever been diagnosed with schizophrenia, schizoaffective disorder, or psychotic disorder?Have you ever experienced hallucinations, delusions, or paranoia?Do you have a history of bipolar disorder or manic episodes?Have you ever been hospitalized for mental health reasons?Do you currently experience suicidal thoughts?
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Do you currently use recreational drugs, including cocaine, amphetamines, stimulants or hallucinogens?Do you drink alcohol at least 5 days per week?Do you take opioid pain medications (e.g., oxycodone, hydrocodone, fentanyl)?
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Have you been diagnosed with liver or kidney disease?Do you have uncontrolled diabetes or hyperthyroidism?Do you have any neurological disorders such as epilepsy or seizure history?Do you have eye disease, such as retinitis pigmentosa or optic neuropathy?Do you have penile anatomical abnormalities (Peyronie’s disease, fibrosis, or scarring)?Have you ever had a prolonged erection lasting more than 4 hours (priapism)?
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No
Are you allergic to ketamine, oxytocin, apomorphine, or sildenafil (or viagra)?
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Please list all current prescription medications, including psychiatric, cardiac, and blood pressure drugs and any over-the-counter supplements or herbal products you take regularly. Dosages not needed.
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Understanding of Treatment Purpose and LimitationsI understand that NexArouse™ is a compounded medication and not FDA-approved as a combination therapy.I understand that results are not guaranteed and that the medication may not improve sexual performance.I understand that this medication is intended for mood-related erectile dysfunction, but may be used for physical ED as well. I understand that emotional, psychological, and relational factors can affect response to treatment.I understand that improvement may require more than one dose or adjunctive therapy.I understand that this medication is for personal use only and not to be shared.
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Safety & Activity RestrictionsI understand I must not drive, operate heavy machinery, or perform tasks requiring full alertness for at least 2 hours after taking NexArouse™, assuming you have taken only 1 tablet. I understand I must avoid alcohol, opioids, or sedatives on the day I take the medication.I understand I must not combine NexArouse™ with nitrates or recreational “poppers”.I understand that I should take only one tablet at a time, and never more than one in 24 hours unless instructed.I understand that if I experience chest pain, vision changes, or an erection lasting longer than 4 hours, I must seek immediate medical attention.
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Informed Consent Statements I have reviewed the potential benefits, risks, and side effects of this medication.I have disclosed all relevant medical history and current medications truthfully.I understand that no permanent benefit is guaranteed, and results may vary.I understand that off-label use is common in medical practice and that NexArouse™ is compounded specifically for my use.I consent to proceed with NexArouse™ therapy under the supervision of my prescribing clinician.
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NEXAROUSE™
30 Sublingual Tablets of Ketamine 15 mg, Apomorphine 2 mg, Sildenafil 50 mg, Oxytocin 50 units
$
250.00
Quantity
1
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