Please read each section carefully. By signing at the end, you confirm you have read and understood this entire document.
1. Provider & Services
Peptide therapy services are provided by a licensed Nurse Practitioner through Lumara Well. All prescriptions are dispensed through a licensed compounding pharmacy. Your provider retains full clinical discretion over the appropriateness of therapy for your health profile.
2. Nature of Peptide Therapy
Peptide therapy uses amino acid chains that interact with receptors in the body to support physiological functions including weight regulation, tissue repair, hormonal balance, immune support, and more. Lumara Well may prescribe peptides including but not limited to: GLP-1 agonists (weight loss), BPC-157 / TB-500 (recovery), Ipamorelin / CJC-1295 / Sermorelin (growth hormone support), PT-141 (sexual health), Thymosin Alpha-1 (immune), AOD-9604, and others.
Many peptides are compounded medications — prepared specifically for you by a licensed compounding pharmacy. They are not FDA-approved as finished drug products in their compounded form, though their active ingredients may have recognized uses.
3. Potential Benefits
Depending on the peptide(s) prescribed, potential benefits may include weight loss and metabolic improvement, enhanced muscle recovery and tissue repair, improved energy, sleep, and mood, hormonal support, immune enhancement, and anti-aging effects. Results are not guaranteed and vary by individual.
4. Potential Risks & Side Effects
Risks may include, but are not limited to:
• Injection site reactions (redness, swelling, bruising, itching)
• Nausea, vomiting, or gastrointestinal discomfort
• Headache, dizziness, or fatigue
• Water retention or changes in blood sugar
• Hormonal fluctuations
• Allergic reaction (rare)
• Drug interactions with current medications
• Unknown long-term risks due to limited long-term clinical data
You agree to notify Lumara Well immediately if you experience any adverse or unexpected symptoms.
5. Patient Responsibilities
By proceeding, you agree to:
• Provide complete and accurate health information
• Disclose all medications, supplements, and health conditions
• Notify your provider of any changes in health status
• Follow all dosing, storage, and administration instructions
• Not share your prescribed peptides with any other person
• Discontinue use and contact your provider if adverse effects occur
6. Compounding Pharmacy
Your peptides will be dispensed by a licensed compounding pharmacy selected by Lumara Well. Compounded medications are not manufactured by a pharmaceutical company and are not FDA-approved as finished drug products. They are prepared specifically for you per your prescription.
7. Telehealth
Services may be delivered via telehealth or online intake. You understand telehealth has limitations compared to in-person care and consent to receiving services in this format.
8. Privacy & HIPAA
Your health information is protected under HIPAA. Lumara Well will not share your personal health information without your consent, except as required by law or necessary for your care (e.g., sending your prescription to the compounding pharmacy).
9. Financial Agreement
Lumara Well does not bill insurance. Peptide therapy is an out-of-pocket expense. You agree to pay all fees at the time of purchase. All sales are final unless otherwise stated.
10. Voluntary Consent & Right to Withdraw
Your participation is entirely voluntary. You may discontinue therapy at any time. Lumara Well reserves the right to decline or discontinue services if therapy is deemed clinically inappropriate for you.
ACKNOWLEDGMENT & SIGNATURE
By signing below, I confirm that:
☑ I have read and understood this entire form — both the health intake and informed consent sections.
☑ All information I have provided is truthful and complete to the best of my knowledge.
☑ I understand the potential benefits and risks of peptide therapy.
☑ I voluntarily consent to peptide therapy through Lumara Well.
☑ I understand that compounded peptides are not FDA-approved finished drug products.
☑ I agree to the financial terms and understand no insurance will be billed.
☑ I understand I may withdraw from therapy at any time.