Peptide Therapy Intake Form

Peptide Therapy Informed Consent & Acknowledgment
Peptide Therapy Consent & Acknowledgment
Patient Name

First NameLast Name
Date of Birth

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Date
Date of Consultation

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Date
Peptide Therapy Education & Disclosure
1. Peptide Therapy Information:

Peptides are short chains of amino acids that act as signaling molecules within the body. Peptide therapies are being studied for their potential role in supporting various biological processes, including tissue repair, recovery, metabolism, inflammation regulation, and overall wellness.

I understand that peptide therapy is an emerging area of wellness and medicine, and scientific research is ongoing. The use of certain peptides may be considered investigational, and many peptides are not approved by the U.S. Food and Drug Administration (FDA) for human use for all applications.
2. Understanding of Benefits & Limitations:

I understand that potential benefits of peptide therapy vary between individuals and may depend on factors including my health status, lifestyle, consistency, and individual response. I understand that results cannot be guaranteed and that peptide therapy is not a substitute for appropriate medical care, diagnosis, or treatment from a licensed healthcare provider.
3. Risks & Possible Side Effects

I understand that peptide therapy may involve potential risks and side effects. These may include, but are not limited to, injection site reactions, redness, swelling, irritation, headache, fatigue, dizziness, changes in appetite, changes in sleep patterns, allergic reactions, or other unexpected responses.

I understand that individual responses may vary and that long-term effects of some peptides may not be fully known.
4. Client Acknowledgment
Peptide Therapy Health Screening
1. Current Health Conditions- Please select any current or past health conditions that apply to you:
2. Please List Current Medications, Peptides, Supplements And Other Wellness Products You Are Currently Using
3. Allergies & Previous Reactions- Please list any allergies, medication reactions, or previous adverse reactions to injections or therapies:
4. Healthcare Provider-Please provide primary healthcare provider name and contact information
5. Medical Disclosure Acknowledgment/ Required
Peptide Therapy Consent & Release Agreement
1.Voluntary Participation-

I acknowledge that my participation in peptide therapy is voluntary. I have had the opportunity to ask questions, seek additional information, and make an informed decision regarding whether to participate.
2.Understanding of Individual Response-

I understand that each individual may respond differently to peptide therapy and that outcomes vary. I understand that no specific results, benefits, or improvements are guaranteed.
3.Treatment Responsibility:

I agree to follow all instructions provided regarding my peptide therapy and to promptly communicate any concerns, unexpected symptoms, or adverse reactions.
4. Release of Liability & Assumption of Risk

To the fullest extent permitted by law, I acknowledge and accept responsibility for the risks associated with peptide therapy. I release and hold harmless Holistic Health Sanctuary and its owners, employees, contractors, and representatives from claims, liabilities, damages, or expenses arising from my voluntary participation, except in cases of gross negligence or willful misconduct.
5. Final Consent Acknowledgment

I acknowledge that I have read and understand this Peptide Therapy Consent & Acknowledgment form. I understand that some peptides may be considered research compounds and that many peptides are not approved by the U.S. Food and Drug Administration (FDA) for human use for all applications. I understand that peptide therapy may involve investigational uses, limitations in available research, unknown long-term effects, and potential risks. I understand that individual responses vary and that no specific outcomes or results are guaranteed. I have had the opportunity to ask questions and voluntarily consent to participate.
Patient Authorization & Electronic Signature
1.Final Agreement/ Required
Patient Signature/ Required
Today's Date

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Practitioner's Notes:
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Peptide Therapy Informed Consent & Acknowledgment

Peptide Therapy Consent & Acknowledgment

Peptide Therapy Education & Disclosure

Peptide Therapy Health Screening

Peptide Therapy Consent & Release Agreement

Patient Authorization & Electronic Signature