Informed Consent for the Use of Compounded Sermorelin

(Telehealth or Brick-and-Mortar)

Date: {{current_date}}

Patient Information

• **Patient Name: {{patient_first_name}} {{patient_last_name}} {{patient_first_name}} {{patient_last_name}}** {{patient_input}}
• **Date of Birth: {{patient_birthdate}}** {{patient_input}}

Purpose

The purpose of this consent is to inform you of the potential risks and benefits associated with the use of compounded sermorelin and to obtain your informed consent to proceed with this treatment.

About Compounded Sermorelin

This informed consent form is for the use of compounded sermorelin, a medication that is custom-made for individual patients. Compounded medications are not approved by the U.S. Food and Drug Administration and may not have undergone the same level of testing and review as an FDA-approved medication.

Sermorelin is a synthetic (man-made) version of a naturally occurring substance that causes release of growth hormone from the pituitary gland. Growth hormone is naturally produced by the pituitary gland and is necessary for growth in children. In children who fail to grow normally because their bodies are not producing enough growth hormone, this medicine may be used to increase the amount of growth hormone produced by the pituitary gland.

Benefits

Potential benefits may include: Fat reduction (especially abdominal fat), restored vitality, youthful and glowing skin, thicker hair and nails, and an improved sense of well-being. Accelerated healing from wounds or surgery, increase in libido and better sexual performance, improved sleep quality, and better mood.

Usage Instructions

If you are injecting this medicine yourself, use it exactly as directed by your doctor. Do not use more or less of it, and do not use it more often than your doctor ordered. The exact amount of medicine needed has been carefully worked out. Using too much will increase the risk of side effects, while using too little may not improve the condition.

Side Effects and Risks

Along with its needed effects, a medicine may cause some unwanted effects. Although not all these side effects may occur, if they do occur, they may need medical attention.

Tell your doctor if you have ever had any unusual or allergic reaction to this medicine or any other medicines. Also tell your health care professional if you have any other types of allergies, such as to foods, dyes, preservatives, or animals. For non-prescription products, read the label or package ingredients carefully.

Important Safety Information

Compounded medications are not approved by the FDA and may not have undergone the same level of testing and review that the FDA requires for their approval. The safety and efficacy of compounded sermorelin have not been fully established, and there may be unknown risks associated with the use of it.

Signatures

Patient Signature: {{patient_input}} Date: {{patient_input}}

Provider Signature: {{patient_input}} Date: {{patient_input}}

Form Complete