Veteran Owned and Operated

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Sheila L. Uridil, MSN, APRN, AGACNP-BC, ANP-BC
Joseph E. Uridil IV, MSN, APRN, AGACNP-BC
NeighborhoodHealthcareJ.S@gmail.com

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PEPTIDE THERAPY CONSENT FORM

PURPOSE OF PEPTIDE THERAPY
I understand that peptide therapy involves the administration of peptides that may be used to support various health, wellness, or aesthetic goals, including but not limited to metabolism, weight management, muscle recovery, anti-aging, immune support, or hormone-related functions.

I acknowledge that many peptides are considered off-label, investigational, or not FDA-approved for the specific purpose for which they are being prescribed.

VOLUNTARY PARTICIPATION
I understand that participation in peptide therapy is voluntary and that I may decline or discontinue treatment at any time without affecting my ability to receive other medical care.

POTENTIAL BENEFITS
Potential benefits may include improved well-being, body composition, energy, recovery, or other individualized outcomes. I understand that results are not guaranteed and vary from person to person.

RISKS & POSSIBLE SIDE EFFECTS
I acknowledge that peptide therapy carries potential risks and side effects, which may include but are not limited to:

  • Injection site reactions (pain, redness, swelling, bruising)
  • Headache, nausea, dizziness, or fatigue
  • Hormonal changes or imbalances
  • Allergic reactions
  • Unknown or unforeseen side effects due to limited long-term data

I understand that additional risks may exist that are currently unknown.

ALTERNATIVES
I understand that alternatives to peptide therapy may include lifestyle modification, diet, exercise, prescription medications, or no treatment at all. These alternatives have been discussed with me to my satisfaction.

NO GUARANTEE OF RESULTS
I understand that no guarantees or assurances have been made regarding the effectiveness or outcome of peptide therapy.

PATIENT RESPONSIBILITIES
I agree to:

  • Disclose all relevant medical history, medications, and supplements
  • Follow prescribed dosing and administration instructions
  • Report any adverse effects promptly
  • Attend recommended follow-up appointments

Failure to follow medical instructions may increase risk and reduce benefit.

RELEASE OF LIABILITY
To the fullest extent permitted by law, I hereby release, waive, and hold harmless the clinic, provider(s), medical staff, and affiliates from any and all claims, demands, damages, or causes of action arising from or related to my participation in peptide therapy, except in cases of gross negligence or willful misconduct.

ACKNOWLEDGMENT AND CONSENT
I certify that:

  • I have read and understand this document
  • All my questions have been answered to my satisfaction
  • I am legally competent to provide consent

By signing below, I voluntarily consent to peptide therapy.

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