[PRACTICE NAME]
[ADDRESS LINE 1]
[CITY, STATE ZIP]
Phone: [PHONE] | Fax: [FAX]
Informed Consent for Peptide Therapy
Patient Name:
Date of Birth:
Date:
Peptide(s) to be prescribed:
Purpose of This Document
This informed consent document is designed to provide you with important information about peptide therapy so that you can make an informed decision about your treatment. Please read this document carefully and ask any questions before signing.
What Are Peptides?
Peptides are short chains of amino acids that act as signaling molecules in the body. They play important roles in various physiological processes including metabolism, tissue repair, immune function, and hormone regulation. Therapeutic peptides are used to support or enhance these natural processes.
Description of Treatment
Your healthcare provider has recommended peptide therapy as part of your treatment plan. The specific peptide(s), dosage, frequency, and duration of treatment will be determined by your provider based on your individual health needs and goals.
Potential Benefits
The potential benefits of peptide therapy may include, but are not limited to: Note: Individual results vary, and benefits are not guaranteed. Your specific expected outcomes will be discussed with you by your healthcare provider.
Risks and Side Effects
As with any medical treatment, peptide therapy carries potential risks and side effects: This list is not exhaustive. Please report any unusual symptoms to your healthcare provider immediately.
Alternatives to Treatment
Alternative treatments may include:
Contraindications
Peptide therapy may not be appropriate for individuals who:
Patient Acknowledgments
By signing below, I acknowledge and confirm that:
I have read and understand this informed consent document
I have had the opportunity to ask questions and have received satisfactory answers
I understand the potential benefits, risks, and alternatives to peptide therapy
I have disclosed all relevant medical history, medications, and supplements
I agree to follow the treatment protocol and attend scheduled follow-up appointments
I will report any adverse reactions or concerns to my healthcare provider promptly
I understand that I may withdraw consent and discontinue treatment at any time
Patient Signature
Date
Patient Printed Name
Prescriber Signature
Date
Prescriber Printed Name & Credentials

This consent form is valid for 12 months from the date of signature unless revoked earlier by the patient.

A copy of this signed consent will be provided to the patient and maintained in the medical record.

Template provided by PeptidePrescriber.com - For educational purposes only - Review with legal counsel before use