PEPTIDE AND OTHER INJECTABLES CONSENT

Revised June 15, 2026

This is a copy of the consent form signed in the electronic medical health record before initiating treatment.

Pricing and Practice Fees

Peptides are provided to patients at the Practice's acquisition cost without additional markup. In addition to the cost of the peptide, a $100 Practice Fee per vial will be charged to cover the medical oversight, clinical support, and administrative services associated with treatment.

Because peptide availability, vendor sourcing, and market conditions may fluctuate, peptide pricing is subject to change without prior notice. The Practice will communicate any pricing changes before dispensing additional medication.

The $100 Practice Fee includes:

• $30 for clinical dosing review, prescription management, and administrative oversight;

• $30 for side effect monitoring, treatment support, and clinical guidance;

• $40 for concierge communication access, including ongoing messaging and patient support between visits.

The Member acknowledges that medication costs and Practice Fees are separate charges and understands that future pricing may vary based on product availability, vendor costs, and changes in supply.

Compounded Medications

I understand that some medications prescribed through the Practice may be compounded medications obtained from licensed compounding pharmacies. Compounded medications are not FDA-approved and may differ from commercially available brand-name products manufactured by Novo Nordisk®, Eli Lilly®, or other pharmaceutical manufacturers.

Compounding pharmacies utilize pharmaceutical ingredients sourced from FDA-registered suppliers; however, compounded medications themselves are not reviewed, approved, tested, or monitored by the FDA for safety, efficacy, or quality in the same manner as commercially manufactured products.

I acknowledge that compounded medications may have differences in formulation, concentration, inactive ingredients, or route of administration compared to commercially available medications.

I acknowledge that I have discussed with my healthcare provider the potential risks, benefits, alternatives, and unknowns associated with compounded injectable peptide therapy.

I understand and acknowledge the following:

• The injectable peptide product(s) being prescribed/administered are compounded products and may be obtained through a compounding pharmacy and/or laboratory compounding source. My provider will let me know which sources and peptides are available to the state which I reside.

• These products are not FDA-approved for the intended use discussed.

• These products may not have undergone formal human clinical trials establishing safety, efficacy, dosing standards, or long-term outcomes.

• Compounded products are not subject to the same FDA review and manufacturing standards as FDA-approved medications.

• Potential risks may include, but are not limited to:

  • contamination or sterility issues

  • inaccurate dosing or potency variability

  • allergic or adverse reactions

  • injection site reactions

  • unknown side effects or long-term health risks

  • lack of proven effectiveness

I understand that no guarantees or assurances have been made regarding outcomes or benefits of treatment.

I have had the opportunity to ask questions regarding this therapy, and all questions have been answered to my satisfaction. I understand that alternative treatment options may exist, including choosing no treatment.

Compounded Research-Use Peptide Products

I understand that medications prescribed through the Practice may be sourced from licensed compounding pharmacies when available and clinically appropriate. Certain peptides may also be available through research or compounding laboratory formulations when commercially compounded products are unavailable, limited in supply, or otherwise deemed appropriate by my Provider.

I understand that compounding pharmacy formulations are preferred whenever available and clinically appropriate. However, due to market availability, supply chain limitations, regulatory changes, or other factors, the Practice may consider alternative formulations for select peptides.

If treatment with a compounding laboratory or other non-traditional peptide formulation is being considered, my Provider will discuss this recommendation with me during a medical visit. Prior to initiating such treatment, I will be provided with additional information regarding the potential risks, benefits, alternatives, and limitations of the proposed therapy. I understand that a separate written informed consent may be required and must be signed before treatment can begin.

I acknowledge that I will have the opportunity to ask questions regarding any proposed medication or formulation and that I may decline treatment if I do not wish to proceed.

By signing below, I acknowledge that I understand the information above and voluntarily consent to the use of compounded injectable peptide therapy.