Peptide Therapy Form

(Telehealth or Brick-and-Mortar)

Date:

Patient Information

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

Treatment Goals

The goal of peptide therapy is to support and optimize your body's natural functions. Please describe your treatment goals:

Alternative Treatments

I understand that alternative treatments including doing nothing, standard medication use, surgery or other therapeutic intervention, hormone replacement therapy, dietary changes, exercise programs, and other medical interventions, are available and have been discussed with me. Furthermore, I understand that peptide therapy is being used as part of an integrative treatment approach.

Consent Statements

Please initial each statement:

1. I have been informed of the nature of peptide therapy, including its potential benefits, risks, and alternatives.

2. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction.

3. I understand that peptide therapy is not guaranteed to achieve the intended results.

4. I understand that ongoing monitoring may be required.

5. I agree to follow the treatment plan as prescribed and to inform my healthcare provider of any side effects or changes in my health.

Signatures

All medical advice, prescriptive service and administration are performed by a licensed medical provider under an independently owned professional organization. ennu, 25 Again, TryPonce are all trade names owned by BSM Holdings, LLC and therefore do not in any way provide medical care or advice.

Form Complete