Clone of JUVÉDERM® ULTRA/ULTRA PLUS Filler Injection Consent Form

About the Treatment
Peptide therapy involves the subcutaneous or intramuscular injection of short-chain amino acid sequences (peptides) that act as biological messengers, signaling the body to perform specific physiological functions. Peptides used at Nurse G LLC may include — but are not limited to — BPC-157, TB-500 (Thymosin Beta-4), GHK-Cu (Copper Peptide), Sermorelin, and other wellness-focused peptide compounds. Peptide therapy is used to support tissue repair and recovery, cellular regeneration, immune modulation, anti-aging, and overall wellness optimization. All peptides are administered under the clinical supervision of Angelica Gonzalez, APRN, Nurse G LLC.

Risks and Complications
As with any injectable therapy, peptide injections carry potential risks and side effects. These may include: temporary redness, swelling, bruising, or discomfort at the injection site; mild fatigue or flu-like symptoms following administration; water retention; headache; and temporary changes in appetite or energy levels.

In rare cases, patients may experience allergic or hypersensitivity reactions to peptide compounds or the carrier solution. Patients using growth hormone-releasing peptides (e.g., Sermorelin) should be aware of potential effects on hormonal pathways and are advised to disclose all current medications, hormone therapies, and medical history prior to treatment.

Nurse G LLC is not responsible for adverse events resulting from undisclosed medical conditions, pre-existing contraindications, or failure to follow post-treatment instructions. Contact Nurse G LLC immediately if you experience difficulty breathing, chest pain, severe swelling, rash, or any other unusual or severe symptoms following treatment.

Pregnancy / Allergies / Neurologic Conditions

1. Please confirm the following (check all that apply): I am not pregnant, not breastfeeding, and not planning to become pregnant. I do not have an active cancer diagnosis or a history of hormone-sensitive malignancies. I have no known allergies to peptide compounds, amino acids, or the carrier solution ingredients. I am not currently taking medications that may interact with peptide therapy (including insulin, corticosteroids, or other hormone therapies) without prior disclosure to my provider.*

None of the Above

Payment

I Acknowledge

Photo and Video Consent
I authorize Nurse G LLC and its representatives to take clinical photographs and/or videos for documentation and marketing (social media and nurseg.net). These images may be used anonymously for educational or promotional purposes.

✅ I consent to photo/video use❌ I do not consent to photo/video use

Post-Treatment Instructions
After treatment:

Keep the injection site clean and dry for at least 4 hours. Do not touch, rub, or apply pressure to the injection site.

Avoid strenuous exercise, excessive heat, steam rooms, and alcohol for 24 hours following injection.

Stay well-hydrated throughout the day of and the day after treatment.

Monitor for any signs of allergic reaction (rash, swelling, difficulty breathing) and seek immediate medical attention if these occur.

Follow any specific storage or self-administration instructions provided by your provider if applicable.

Results and Expectations
Results from peptide therapy vary significantly based on the specific peptide(s) administered, the patient's individual physiology, lifestyle, and consistency of treatment. Peptide therapy is generally intended as a supportive, cumulative treatment — optimal outcomes are typically achieved over a series of sessions. No specific outcomes, timelines, or results are guaranteed. Nurse G LLC and its providers make no warranties regarding treatment efficacy and are not responsible if anticipated results are not achieved.

Acknowledgment and Consent
I have read and fully understand this consent form. My questions have been answered to my satisfaction. I accept the potential risks and understand that results may vary.

✅ I consent to treatment❌ I do not consent

Patient Name*

Patient Birth Date *

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Date Signed

Date

Hour MinutesAM/PM Option

Signature*

Please review the following information carefully and complete all required fields before treatment.