Peptide Therapy Waiver Form


Peptide Therapy Waiver

This agreement is entered into between ("Patient") and Nouveau Aesthetics (provider), the licensed healthcare provider administering peptide therapy ("Provider"). By signing below, the Patient acknowledges and agrees to the terms and conditions outlined in this waiver.

Purpose of Peptide Therapy

Peptide therapy is an experimental or alternative treatment involving the use of synthetic peptides, which are short chains of amino acids. These peptides may be used to promote various physiological processes such as muscle growth, fat loss, immune function enhancement, anti-aging benefits, and recovery from injuries. Peptides are being studied for a wide range of potential therapeutic uses, but may not have been fully researched or approved by regulatory authorities such as the U.S. Food and Drug Administration (FDA) for all intended uses.

Some of the Peptides include but are not limited to:

  • PT 141
  • BPC - 157
  • Sermorellin
  • Wolverin Stack
  • GHK-Cu
  • NAD +
  • Tesamorellin
  • CJC- 1295
  • HCG (1200 iu)
  • IGF-1 LR3
  • 2x Blend: CJC 1295/Ipamorellin (5mg)
  • 2x Blend: Tesamorellin (10 mg)/Ipamorellin (5mg)
  • 3x Blend: Tesamorellin (5mg)/MGF (500 mcg)/Ipamorellin (2.5 mg)

Potential Benefits of Peptide Therapy

  • Enhancement of muscle growth and strength
  • Improvement of fat metabolism and weight management
  • Improvement in skin elasticity and appearance
  • Reduction of inflammation and pain relief
  • Increased energy and overall wellness
  • Support of immune system function
  • Improved recovery time from physical exertion or injury

Potential Risks and Side Effects

While many individuals may experience positive effects from peptide therapy, there are also risks and side effects associated with the treatment. By agreeing to this waiver, the Patient acknowledges the following potential risks:

  • Allergic Reactions: Rash, itching, or swelling, particularly around the face, tongue, or throat, which may cause difficulty breathing.
  • Increased Risk of Infection: Due to the use of injections, there may be a risk of infection if proper technique and hygiene are not followed.
  • Unanticipated Health Conditions: There may be unforeseen adverse effects based on the individual’s unique medical conditions, medication interactions, or genetics.
  • Lack of Long-Term Data: Peptide therapy may not have been studied extensively for long-term effects, and there may be unknown risks.
  • Possible Interaction with Other Medications: Peptides may interact with prescription medications or other supplements, potentially leading to adverse effects or complications.
  • Injection Site Reactions:
    • Pain, redness, or swelling: These are common at the injection site, especially if the peptide is administered subcutaneously.
    • Infection risk: Improper technique or unclean needles can introduce bacteria, leading to infections.
  • Hormonal Imbalances
    • Some peptides can influence hormone levels, leading to imbalances in the body. For example, growth hormone-releasing peptides (GHRPs) can increase growth hormone levels, which may cause:
    • Increased risk of diabetes: High growth hormone levels can affect insulin sensitivity, potentially leading to insulin resistance.
    • Fluid retention: Elevated growth hormone can lead to water retention, causing bloating or swelling.
    • Joint pain: Due to excess growth factors, some individuals experience discomfort in their joints.
  • Immune System Effects
    • Autoimmune reactions: Rarely, some peptides may trigger immune system responses, causing allergic reactions or autoimmune-like conditions.
  • Elevated Blood Pressure
    • Certain peptides, such as those influencing growth hormone or other regulatory peptides, can lead to an increase in blood pressure, especially if used in high doses.
  • Potential Impact on Organ Function
    • Long-term use of certain peptides could stress organs like the kidneys or liver, especially if they’re involved in metabolism or processing the peptides.
  • Gastrointestinal Issues
    • Some individuals may experience digestive issues such as nausea, cramps, or diarrhea, particularly with peptides that affect gut motility.
  • Changes in Skin and Hair
    • Acne: Peptides like growth hormone can cause acne due to changes in skin oil production.
    • Hair thinning: Some users report hair loss or thinning with certain peptides, especially those affecting growth hormone pathways.
  • Psychological Effects
    • Mood swings or irritability: Elevated hormones can sometimes cause mood changes or anxiety.
  • Overuse or Abuse
    • The use of peptides without proper medical supervision or excessive dosing can lead to more severe side effects, including excessive tissue growth (e.g., organ enlargement) or long-term health complications.

Alternatives to peptide therapy

  • Hormone replacement therapy
  • Stem Cell Therapy
  • PRP (Platelet Rich Plasma)
  • Nutritional Supplementation
  • Exercise and Physical Activity
  • Botox & Dermal Fillers
  • Anti-aging and regenerative medicine
  • Acupuncture
  • Corticosteroid injections
  • Cryotherapy
  • Lifestyle changes

*** Contraindications of peptide use ***

Peptide therapy can be highly effective for certain medical conditions, but it's not suitable for everyone. There are several groups of people who may be advised against using peptide therapy or need to exercise caution. Here are some of the individuals who should generally avoid peptide therapy:

  1. Pregnant or Breastfeeding Women
    • Lack of safety data: There is limited research on the effects of peptides during pregnancy or breastfeeding. Peptides may have unknown effects on fetal development or infant health, so it’s recommended to avoid peptide therapy during these times unless specifically prescribed by a healthcare provider.
  1. People with Allergies to Peptides
    • Allergic reactions: Some individuals may be allergic to certain peptides, leading to potential reactions such as rashes, swelling, or difficulty breathing. If you have known allergies to peptides or similar compounds, peptide therapy should be avoided.
  1. Individuals with Active Cancer or a History of Cancer
    • Growth stimulation: Many peptides, especially growth hormone-related peptides, stimulate cell growth. In cancer patients, this could potentially stimulate the growth of existing cancer cells. As a result, peptide therapy is generally contraindicated for those with active cancer or a history of cancer unless specifically directed by an oncologist.
  1. People with Hormonal Disorders
    • Thyroid, adrenal, or pituitary issues: Peptides can influence hormone production, and in people with existing hormonal imbalances (e.g., thyroid issues, adrenal problems), this could exacerbate the condition. Peptide therapy should be carefully managed and closely monitored by a doctor in such cases.
  1. People with Diabetes or Insulin Sensitivity Issues
    • Impact on insulin and blood sugar: Some peptides, especially those that stimulate growth hormone or growth hormone-releasing peptides, can affect insulin sensitivity, potentially leading to insulin resistance or worsening diabetes control. People with diabetes should consult their healthcare provider carefully before considering peptide therapy.
  1. Individuals with Kidney or Liver Impairment
    • Organ stress: Peptides are metabolized by the liver and kidneys, so individuals with pre-existing liver or kidney conditions may face increased stress on these organs. In some cases, peptides can exacerbate liver or kidney function issues, making therapy potentially unsafe for these individuals.
  1. People with Immune System Disorders
    • Autoimmune conditions: Some peptides may affect immune function or trigger autoimmune-like reactions in vulnerable individuals. People with autoimmune diseases or those with weakened immune systems may need to avoid peptide therapy or use it with caution.
  1. Children and Adolescents (without medical supervision)
    • Underdeveloped systems: The hormonal effects of peptides can interfere with a developing body. While peptides like growth hormone are sometimes used in children with specific growth-related disorders, peptide therapy for general health or performance enhancement should not be used without strict medical oversight in younger populations.
  1. Individuals with Heart Disease
    • Potential cardiovascular effects: Certain peptides, particularly those that influence growth hormone or stimulate growth factors, can affect fluid balance and blood pressure. This could potentially worsen cardiovascular conditions, so individuals with heart disease should avoid peptide therapy unless prescribed and monitored by a cardiologist.
  1. People with Psychological Disorders (e.g., Anxiety or Mood Disorders)
    • Potential psychological side effects: Some peptides, especially those that influence hormone levels, may cause mood swings, irritability, or anxiety. Individuals with existing mood disorders may experience exacerbated symptoms, so they should be cautious when considering peptide therapy.
  1. Individuals Taking Certain Medications
    • Drug interactions: Some medications may interact with peptides, either decreasing their effectiveness or causing unwanted side effects. People taking medications for conditions like hypertension, blood thinners, or other chronic conditions should consult with their healthcare provider before using peptides.
  1. People with Active Infections
    • Immune system burden: Peptide therapy, particularly if administered through injections, can sometimes put additional strain on the immune system, which could be a concern for individuals with active infections.

Recommendations during peptide use

When undergoing peptide therapy, it's essential to follow certain medical recommendations to maximize safety and efficacy while minimizing potential risks or adverse effects. Here are some key medical guidelines to consider during peptide therapy:

  1. Consult a Healthcare Provider
    • Pre-therapy evaluation: Before starting peptide therapy, have a comprehensive evaluation by a healthcare provider to ensure peptides are appropriate for your condition and to identify any contraindications.
    • Ongoing monitoring: Regular check-ins with your healthcare provider are crucial to assess the effectiveness of the therapy and to monitor for any potential side effects or complications.
  1. Adhere to Proper Dosage and Administration
    • Follow prescribed dosage: It's important to adhere strictly to the dosage recommended by your doctor. Overuse or misuse of peptides can lead to serious side effects.
    • Injection technique: If your therapy involves subcutaneous or intramuscular injections, ensure that you're trained in proper injection techniques to avoid complications such as infections, abscesses, or incorrect dosing.
    • Injection site rotation: If you are administering peptides through injections, rotate injection sites to minimize irritation or the formation of scar tissue at any one location.
  1. Monitor Hormonal Levels
    • Regular blood tests: Peptides, especially those that influence hormones (e.g., growth hormone, growth hormone-releasing peptides), can alter hormone levels. Regular blood tests to monitor these levels are important to prevent any imbalances.
    • Check for side effects: Symptoms such as joint pain, water retention, or unexpected weight gain might indicate that hormone levels are too high, requiring adjustments in therapy.
  1. Watch for Adverse Reactions
    • Skin reactions: Keep an eye on the injection sites for signs of infection (redness, swelling, pain) or allergic reactions.
    • Systemic reactions: Pay attention to signs of systemic side effects, such as changes in mood, increased blood pressure, headaches, or gastrointestinal issues.
    • Seek immediate medical help: If you experience signs of a severe allergic reaction (e.g., difficulty breathing, swelling of the face or throat, rash), seek medical attention immediately.
  1. Stay Hydrated and Maintain a Balanced Diet
    • Hydration: Peptide therapy, especially growth hormone-related therapies, can lead to fluid retention. It's important to stay well-hydrated, but avoid overconsumption of water to balance fluid levels properly.
    • Nutrition: A balanced diet that supports your body's nutritional needs is essential during peptide therapy. Protein intake, for example, should align with your health goals (e.g., muscle growth or tissue repair) and support peptide efficacy.
  1. Monitor Blood Sugar and Insulin Sensitivity
    • Check glucose levels: Some peptides, particularly growth hormone-related peptides, can impact blood sugar and insulin sensitivity. It's important for individuals with diabetes or those at risk for diabetes to monitor blood glucose levels regularly.
    • Manage insulin use: If you're diabetic or have insulin sensitivity issues, closely monitor how peptide therapy is affecting your insulin levels and consider adjusting insulin doses under your doctor's supervision.
    • Contact your PCP or Endocrinology specialist in charge of your medical condition for any medical prescription changes or alternative treatment options.
  1. Avoid Using Peptides for Unapproved Purposes
    • Follow approved guidelines: Peptide therapy should be used only for conditions where it is medically indicated. Using peptides for off-label purposes, such as for performance enhancement or anti-aging without medical supervision, can be risky.
  1. Stay Informed about Potential Drug Interactions
    • Consult with your doctor about other medications: Peptides may interact with other medications or supplements. Always inform your healthcare provider about all the medications you're taking to avoid adverse interactions.
    • Avoid certain substances: Depending on the peptide being used, your doctor may recommend avoiding certain substances (like alcohol or stimulants) that can interfere with peptide efficacy or increase the risk of side effects.
  1. Monitor Organ Function
    • Check kidney and liver function: Since peptides are processed by the liver and kidneys, it’s important to monitor these organs, especially if you have a pre-existing condition that affects their function. Regular blood tests to assess liver enzymes and kidney function are advised.
    • Tumor markers and cancer marker lab work is recommended prior to starting peptide therapy, due to risk of enlargement of any “active tumor, growth, or masses” in the body during the time of use of peptide therapy.
  1. Take Breaks When Recommended
    • Cycling therapy: Some peptides are used in cycles (e.g., taking them for a few weeks, followed by a break). Follow the recommended protocol for cycling peptide therapy to avoid overstimulation of certain bodily processes, such as hormone production.
  1. Avoid Use in Certain Populations
    • Pregnancy and breastfeeding: As mentioned earlier, peptides should be avoided during pregnancy and breastfeeding unless specifically prescribed by a healthcare provider.
    • Children and adolescents: Peptides should only be used in children or adolescents under strict medical supervision for approved indications.
  1. Consider Potential Long-Term Effects
    • Research and education: While peptides are often used to improve health, muscle growth, or tissue repair, long-term effects may not be fully understood. Stay informed by discussing with your healthcare provider about the risks and benefits of continued peptide use.
    • Alternative treatments: In some cases, there may be safer or more established treatments available, so it's important to discuss these options with your doctor.

Acknowledgment of Informed Consent

The Patient understands that peptide therapy is an evolving and individualized treatment. The Provider has informed the Patient of the potential benefits, risks, and alternatives to peptide therapy. The Patient has had the opportunity to ask questions and has received satisfactory answers.

The Patient acknowledges that no specific outcome or result is guaranteed, and that responses to peptide therapy can vary from person to person. The Patient understands

that peptide therapy may not be appropriate for everyone and agrees to discuss any pre-existing health conditions or concerns with the Provider before beginning treatment.

Release of Liability

By signing this waiver, the Patient agrees to release, indemnify, and hold harmless the Provider, their staff, and affiliates from any and all claims, demands, damages, or legal actions arising from or related to peptide therapy, including but not limited to any potential adverse effects, complications, or injuries.

Voluntary Participation

The Patient affirms that their participation in peptide therapy is voluntary, and they have made this decision freely and with a full understanding of the potential risks and benefits involved.

Confidentiality

The Provider will take all reasonable measures to protect the Patient’s privacy and confidentiality, consistent with applicable laws and regulations. The Patient’s health information will be shared only with authorized individuals or organizations in accordance with relevant healthcare laws.

Conclusion

By signing below, the Patient acknowledges that they have read, understood, and voluntarily agreed to the terms of this Peptide Therapy Risk and Benefit Waiver.

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Document name: Peptide Therapy Waiver Form
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April 24, 2025 4:33 am ESTPeptide Therapy Waiver Form Uploaded by Geoffrey Firmin - Firmin.aesthetics@gmail.com IP 106.219.145.233
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