Z Medi Clinics and Z Medi Spa
Consent To Anti-Aging Peptide Therapy
Since the early 1960s, the U.S. Food and Drug Administration (FDA) has required that drugs used in the United States be both safe and effective. The label information on the container, in the package insert, in the Physicians’ Desk Reference, and in any advertising can indicate a drug’s use only in certain “approved” doses and routes of administration for a particular condition. The use of a drug for a condition, in a dose, or by a route not listed on the label is considered to be a “nonapproved” or “off -label” use of the drug. Prescribers—based on their knowledge, education, training, experience, and available current information—may use a drug for a use, in a dose, or by a route not indicated in the “approved” labeling if it seems reasonable or appropriate in the prescriber’s professional judgment.
Purpose: I hereby authorize practitioners with this clinic to provide medical care to me, including but not limited to Anti-Aging Peptide Therapy such as Sermorelin, Ipamorelin, CJC-1295, GHRP2, GHRP6, kisspeptin.
I understand that the use of this therapy may be debated in the traditional medical community.
Peptides are small chains of amino acids that can have biological activity. They are mostly naturally occurring. Some peptides are FDA approved for the treatment of certain diseases. Other peptides used clinically are prepared by duly registered compounding pharmacies complying with all state and federal laws. Peptides can be administered in various presentations, including but not limited to oral, intravenous, subcutaneous, intramuscular and intranasal routes.
Treatment Regime: I have been advised that the practitioners with this clinic may prescribe Peptide Therapy to augment production of growth hormone by the body in certain situations that it may be deemed beneficial.
Understanding this, I hereby acknowledge and consent to the following:
- My providers at Z Med Clinics, have discussed with me the possibility of integrating peptide therapy into my current treatment regime.
- I understand that the use of these peptides may not be a current FDA approved use in my particular case and that my licensed providers intend to follow the principles of the practice of medicine and the laws regulating compounding pharmacies, as a complement to my current treatments.
- As with any other drug, peptide therapies can have side effects, including but not limited to:
- Injection site reactions (pain, rash, bleeding)
- Allergies, including life threatening reactions
- I understand that alternatives to peptide therapy are:
- Do nothing
- Standard medication use
- Surgery or other therapeutic intervention
- I furthermore understand that Peptide therapy is being used as part of an integrative treatment approach
Having read this, I hereby acknowledge that I am voluntarily undergoing peptide therapy and that I hereby relieve Z Med Clinics’ medical directors, providers, staff, managers, officers and associates of any legal responsibility regarding side effects or complications that may occur due to receiving peptide therapies.
I certify that if any concerns or side effects occur, I will promptly notify Z Med Clinics’ providers. I also understand that Z Med Clinic is not responsible for any manufacturing issues related to these peptides, such as sterility and potency, which are the sole responsibility of the compounding pharmacy preparing them.
I certify that I understand all the above information and that I have no questions about this.
Consent to treatment by a physician extender: You may be evaluated and treated by a physician assistant (P.A.) or a nurse practitioner (N.P.) whose recommended care and treatment is subject to supervision and review by a licensed physician.
I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM AND I REALIZE I SHOULD NOT SIGN THIS FORM IF ALL ITEMS HAVE NOT BEEN SATISFACTORILY EXPLAINED TO ME. WITH MY SIGNATURE I ACKNOWLEDGE THAT MY QUESTIONS HAVE BEEN ANSWERED FULLY, AND THAT I HAVE BEEN REQUESTED TO READ THIS FORM AND HAVE BEEN GIVEN AMPLE TIME TO UNDERSTAND ALL ITS CONTENTS.