Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.FORM #1 - INFORMED CONSENT FOR PEPTIDE THERAPY There are three forms to complete for online orders. Please review and complete each form. What therapeutic peptides are you interested in? (Check one or more) *Growth Peptide / CJC-1295 + IpamorelinHealing Peptide / BCP-15Tissue Repair Peptide / TB-500Anti-Aging Peptide / GHK-CUEnergy And Longevity Peptide / NADPurpose: The purpose of this document is to provide written information regarding the risks, benefits, and alternatives to the experimental/investigational use of research peptides. This consent supplements discussions with your provider and documents your understanding of the nature of the peptides being used and the potential considerations involved. It is essential that you fully understand this information – please read this document carefully. Name *FirstLastThe named individual above has been advised and consulted about the use of research-only peptides. I understand that these peptides are not approved by the Food and Drug Administration (FDA) for the treatment, diagnosis, or prevention of any disease or medical condition. While there may be scientific interest in the potential benefits of these peptides, they have not undergone the rigorous clinical trials required for FDA approval. Acknowledgement and Consent #1 *By checking here, I acknowledge that this is an experimental/investigational procedure that is NOT FDA-approved. NOVA Pain & Rehab Center and its medical staff make no claims or guarantees regarding effectiveness in my case, regardless of any external information I may have encountered.Procedure & Protocols: The peptides used in this office have been independently tested for purity and safety but remain classified as research compounds. These peptides may be used to support various physiological functions as determined by your provider. However, their safety and long-term effects in human applications are not fully established. The provider will determine the appropriate administration technique based on my specific goals and treatment plan. Potential Benefits: Expected benefits MAY include, but are not guaranteed: • Support for cellular function • Anti-inflammatory effects • Tissue repair support • Metabolic enhancement However, no results are guaranteed, and responses vary by individual. Potential Risks & Adverse Reactions: As with any procedure, potential risks exist. While research peptides are generally well-tolerated, possible risks include but are not limited to: • Redness, swelling, or discomfort at the injection site • Temporary itching or irritation • Allergic reaction (rare but possible) • Infection (rare with proper technique) • General dissatisfaction with results • Unknown long-term effects, as these peptides are not clinically studied for human use If I experience any adverse effects, I will contact my provider immediately. Alternatives: I have been advised of alternative treatment options, including: • Doing nothing, with associated risks depending on my condition. • FDA-approved treatment options that may be available. • Lifestyle modifications and other wellness strategies. I am voluntarily choosing research-only peptide therapy after discussing these options with my provider. Acknowledgement and Consent #2 *I understand that research peptides are not FDA-approved and are considered experimental/investigational.Acknowledgement and Consent #3 *I understand that no claims, guarantees, or warranties have been made regarding their results.Acknowledgement and Consent #4 *I acknowledge that I am financially responsible for this elective treatment, which is not covered by insurance, and that payments are non-refundable.Acknowledgement and Consent #5 *I have disclosed all relevant medical history, medications, allergies, and conditions to my provider.Acknowledgement and Consent #6 *I acknowledge that I have been given the opportunity to ask questions, and my provider has addressed them to my satisfaction.I consent to the use of research-only peptides and assume all associated risks. I understand that if I am unwilling to accept these risks, I have been advised not to proceed. I certify that I have read this document, understand its contents, and am capable of executing this informed consent. Enter Today's Date *Enter Your Name *FirstLastSignature (Type Your Name) *FORM #2 - THERAPEUTIC PEPTIDE QUESTIONNAIREEnter Your Name Again *FirstLastAddress *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *EmailConfirm EmailDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone *Health and Background InformationAge *Gender *--- Select Choice ---MaleFemaleOccupation *Smoking status *--- Select Choice ---Never SmokedFormer SmokerCurrent SmokerList any health problems or limitations *List any allergies or intolerances: *Have you been diagnosed with endocrine tumors (MEN 2) or if someone in your family had these tumors? *YesNoHave you been diagnosed with thyroid cancer or if someone in your family had thyroid cancer? *YesNoHow would you rate the stress in your life, 10 being the highest? Selected Value: 1 How do you cope with stress? *What are your goals with Therapeutic Peptides? *Which peptides would you like to discuss? (Check one or more) *Growth Peptide / CJC-1295 + IpamorelinHealing Peptide / BCP-15Tissue Repair Peptide / TB-500Anti-Aging Peptide / GHK-CUEnergy And Longevity Peptide / NADHave you tried Peptides in the past? *YesNo stress you you Are you OK with injecting yourself using the medication? *YesNoAny other questions or items you would like to discuss? *FORM #3 - CREDIT CARD PAYMENT FORMName on Card *Credit Card Number *Expiration Date *Billing Zip Code *CCV# *Signature (Type your Name) *Amount to be Paid *Promo Code (optional)After you press submit, our office will be in touch with you to answer any questions you have and to confirm your order. Thank you! Submit
