1. About You

Your name:

Date of birth:

Today’s date:

Chart number:

2. Who Is Treating You

Your provider is Genevieve George, PA-C, a Physician Assistant licensed in Ohio. She works under the supervision of Dr. Dominic Haynesworth, Medical Director of Advanced Skin Renewal.

      
• Your first visit and prescription happen in person.
      
• You must come in for a follow-up at least once every three months while on therapy.
      
• Missed follow-ups may end your therapy.
    

I read Section 2.   Initials:

3. What Peptide Therapy Is

Peptides are short chains of amino acids — the building blocks of proteins. Some are FDA-approved; others aren’t, but can be legally prescribed when a licensed pharmacy compounds them for you specifically. We give peptides as subcutaneous injections (small shots under the skin). Most patients learn to inject themselves at home after we train them.

4. Important Things to Know About Your Medication

4a. FDA-approved drugs used "off-label"

I understand off-label use, if it applies.   Initials:

4b. Compounded medications from a 503A pharmacy

I understand my medication is compounded.   Initials:

4c. Peptides the FDA has flagged for safety concerns

I understand and accept these added risks.   Initials:

5. Your Goals — and No Promises

No promises about results. People respond differently. Advanced Skin Renewal, your provider, and the Medical Director can’t guarantee any particular outcome.

6. Possible Side Effects and Risks

I read Section 6 and asked my questions.   Initials:

7. Reasons This Might Not Be Safe for You

I confirm my medical history is true and complete.   Initials:

9. Injecting Yourself at Home

We’ll train you. After that, you’re responsible for:

      
• Following the dosing schedule — don’t change it on your own
      
• Storing the medication exactly as instructed (usually refrigerated)
      
• Inspecting before each injection
      
• Using a new sterile needle and syringe every time
      
• Disposing of needles properly
      
• Never sharing your medication
    

12. What You’re Agreeing To

By signing below, I confirm:

      
1. I read this form and understand it.
      
2. I had a chance to ask questions.
      
3. I understand the risks, off-label use, compounded medications, and limits of what’s known.
      
4. No one promised me a specific result.
      
5. I am at least 18 and able to make my own medical decisions.
      
6. I give my consent freely.
    

13. Signatures

Patient Printed Name:

Patient Signature (type full name):

Date: