1. Cardiovascular (heart or blood pressure): These problems may include heart palpitations, irregular beats, or rapid heartbeat. These effects are usually mild but can result in serious problems including heart attack or stroke. Also, these medications may increase blood pressure, which if left untreated can lead to heart attack or stroke. If you discontinue the weight loss medication, the elevated blood pressure usually resolves. For this reason, if you are on blood pressure medications you are required to monitor your blood pressure daily and discontinue medications if blood pressure rise, your heart rate increases, or you feel palpitations. (Please initial)
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4. Gall Bladder Disease: Any program resulting in rapid weight loss may precipitate the formation of gallstones, which could lead to cholecystitis (inflammation of your gallbladder), which is a medical urgency or emergency and could require surgery. This is typically because of the rapid weight loss, not the medications you are taking. Symptoms include right upper abdominal pain, abdominal just below your ribs, nausea, and vomiting. (Please initial)
6. Psychiatric: There are reported cases of “hysterical or psychotic reactions” associated with the use or discontinuation of some of the drugs utilized for weight loss purposes. These reactions are extremely rare. (Please initial)
Peptides are amino acids that have biological activity which mimic certain hormones within the body. Peptides have the ability of increasing certain naturally producing hormones within the body to illicit a certain effect which will be discussed by Pro-Health & Wellness. Certain peptides are FDA approved for the treatment of various diseases while other peptides are investigational new drugs that are not FDA approved to be marketed for consumption in of humans even though clinical trials have shown them to have a favorable safety profile.
Peptide therapy for the purpose of preventative care, weight loss, performance enhancement, anti-aging, and any additional condition discussed by Pro-Health & Wellness is considered by the FDA to be “off-label use.”
Peptide therapy can be administered either orally, subcutaneously, intramuscularly, intravenously, or intranasally. The various preparations will be discussed with me by Pro-Health & Wellness.
Peptide therapies being administered Pro-Health & Wellness are prepared by registered compounding pharmacies that comply with all state and federal regulations.
I acknowledge that Pro-Health & Wellness is not responsible for any manufacturing issues related to peptides prepared by compounding pharmacies and that the sole responsibility for sterility, potency, and safety lie with these pharmacies.
I understand that peptide therapies are not necessarily approved for my medical conditions and they are not a medical necessity, rather, they are an adjunctive and complimentary therapy to my treatment plan. Therefore, I acknowledge that it is an elective treatment option.
I understand that with any drug, peptide therapies can carry potential side effects, including but not limited to:
I understand that alternatives to peptide therapy are: Doing nothing FDA approved standard medication treatments Referral to specialists. Surgery
I acknowledge that there are no guarantees relating to the efficacy of peptide therapies and that Pro-Health & Wellness are not responsible for my individual performance and ability to also exercise and diet.
I certify that I will notify Pro-Health & Wellness immediately if I have any concerns or side effects.
I certify that I have had the risks and benefits discussed with me about peptide therapy and that I have had all my questions and concerns answered to my satisfaction by Pro-Health & Wellness
I hereby voluntarily consent to be evaluated and treated Pro-Health & Wellness with the goal of improving my health, performance, and possibly delaying the effects of aging through peptide therapies.
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I understand that compounded BHRT and Peptide therapy is not specifically approved by the FDA for preventive medicine and my request for BHRT is off-label.
There has been little research regarding the safety of peptide therapy in pregnant and breast-feeding women. I certify that I am not pregnant nor plan on becoming pregnant while on peptide therapy.
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I understand that any hormone replacement including BHRT has the potential to increase my risk of breast cancer and for this reason it is recommended that I have routine mammograms every 1-2 years after age 40 and prior to starting HRT.
I understand that while Testosterone, BHRT and peptide therapy has been shown in medical literature to have benefits in women, that it is not currently FDA approved for the use in women and that if I choose to undergo this treatment, it is an off label treatment.
I understand that this treatment requires routine lab monitoring.
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