Informed Consent for Peptide Therapy

The explanation I have received includes the following:

1. The nature and extent of the procedure to be performed.
2. I understand that peptide injections are offered as an elective wellness service intended to support general well-being. I acknowledge that these elective procedures are not intended to diagnose, treat, cure, or prevent any medical condition.
3. I understand and acknowledge the following: The peptide compounds used in this procedure are not approved by the U.S. Food and Drug Administration (FDA) for the diagnosis, treatment, mitigation, or prevention of any disease or medical condition. Peptides have not undergone FDA evaluation for safety, effectiveness, or quality for human use. Peptide therapy is considered investigational and may involve risks that are not fully known.
4. I understand that compounded peptides are not manufactured under FDA drug-approval standards. Potency, purity, and consistency may vary between batches. The medical center/medical spa cannot guarantee the quality or composition of compounded products beyond what is provided by the compounding pharmacy.
5. The most commonly occurring risks associated with the procedure, as well as those that are unlikely to occur but may result in serious consequences include, but are not limited to: injection site reactions (swelling, redness, discomfort), hormonal imbalances, digestive discomfort, skin irritation, organ damage, fatigue, headache, nausea, dizziness, allergic reactions, risks of infection, and unknown or unexpected adverse effects due to limited clinical research.
6. You may decline or discontinue this procedure at any time without affecting your access to other services.
7. I am aware that if I develop any life-threatening symptoms, I should seek treatment at an Emergency Room, Urgent Care Center, or from my primary care physician. I understand that Arctic Medical Center and its staff, subcontractors, practitioners, owners, and employees will not be responsible for the costs of, or the management of, any subsequent medical care related to complications arising from my elective procedure, as complications are a possible outcome of any medical or surgical procedure.
8. I understand that this procedure is elective and may not be covered by my insurance.
9. I understand the estimated duration of incapacity or convalescence, if any.
10. I understand the risks and benefits of this procedure, as well as the risks and benefits of any reasonable alternatives, such as speaking with another licensed healthcare provider, change in lifestyle choices, and the option of not undergoing the procedure.
11. I understand that I may request additional information about alternatives at any time.
12. I understand the likelihood of success and complications associated with the procedure, with the possibility of adverse reactions leading to the possibility of death.
13. I was given the opportunity to ask any questions I have regarding the procedure, and all those questions have been answered to my satisfaction.
14. I understand that I may seek a second opinion from another physician regarding this procedure.
15. I understand that I have the right to refuse any medical procedure recommended to me at any time prior to the procedure, and I have voluntarily chosen to proceed with this procedure.
16. I authorize my practitioner to perform any additional procedures deemed necessary or appropriate to aid in the diagnosis or to facilitate the procedure, as determined by the practitioner’s professional judgment.
17. In the event that a condition arises during the procedure that requires transportation to a hospital, additional procedures, operations, or medication (including anesthesia and blood transfusions), I further request and authorize the practitioner to take any action deemed necessary on my behalf.
18. I am aware that this (Peptide Therapy) is a voluntary procedure and that Arctic Medical Center & Spa and its providers will not be held liable for undesired outcomes. I understand that there may be situations outside the control of the provider, such as unforeseen complications.
19. I authorize the participation of my practitioner, and the presence of a representative or technician from a medical device company during the procedure. I also consent to medical photography being used for medical, scientific, or educational purposes, provided my identity remains anonymous.
20. I affirm that I have provided accurate and complete information regarding my medical history, medications, allergies, and health conditions. I understand that withholding information may increase my risk of adverse effects.
21. I acknowledge that I have read (or had read to me) and fully understand the information provided above. Furthermore, I certify that all my questions and concerns regarding the procedure, its risks, benefits, and alternatives, have been addressed to my satisfaction. I hereby authorize Arctic Medical Center to perform the aforementioned procedures.

Patient’s Signature / Power of Attorney / Guardian

I verify that I have explained the contents of this document to the patient or the person granting consent. It is my professional opinion that the person providing consent fully understands the subjects discussed.

 

Practitioner/Physician Signature