Consent (Pregnancy Risk):
I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus.
I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.
I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.
By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
Sermorelin and tesamorelin may affect blood sugar control by increasing growth hormone and IGF-1 activity, which can reduce insulin sensitivity in some patients. If you have diabetes, prediabetes, or take medications such as insulin or other glucose-lowering treatments, these therapies may change your blood sugar levels or require adjustments to your diabetes medications. Monitoring blood glucose and/or A1c during therapy is recommended. Please report any significant changes in blood sugar readings, increased thirst, frequent urination, blurred vision, fatigue, or symptoms of low blood sugar to your provider.
Sermorelin and tesamorelin can affect thyroid function by influencing how the body produces and converts thyroid hormones. If you have hypothyroidism or take thyroid medication, these treatments may alter your hormone levels or require adjustments to your thyroid dose. Monitoring thyroid function during therapy is recommended. Please report any changes in energy, mood, or temperature tolerance to your provider, as these may indicate a change in thyroid balance.
Consent:
Medications such as sermorelin and tesamorelin are medications that may be prescribed to support your metabolism, though it is not FDA-approved for this specific use. Its application for metabolism support is considered off-label, meaning it is prescribed by your healthcare provider despite not being specifically approved by the FDA for this purpose. The purpose of this consent form is to ensure that you understand the following:
Please read this document carefully.
Sermorelin and tesamorelin are being considered as a treatment option to potentially improve your metabolic support by acting as a synthetic analogue of growth hormone-releasing hormone (GHRH), which stimulates the secretion of growth hormone (GH). Growth hormone plays a critical role in:
By promoting the natural production of GH, these medications may provide the following benefits:
It is commonly used for purposes like weight loss, muscle gain, and anti-aging therapy.
As previously mentioned, the use of sermorelin and tesamorelin to increase growth hormone levels is considered off-label. While legally prescribed, it is not an FDA-approved indication.
Like any medication, these comes with potential risks and side effects:
Common side effects:
Less common but more serious risks:
There are also concerns regarding the long-term use and its potential link to increased cancer risk. While there is no definitive evidence directly linking these to cancer, some studies suggest that prolonged use of growth hormone therapies could potentially increase the risk of certain cancers due to hormonal imbalances. Since these products stimulate the production of growth hormone, it may influence the development of cancerous cells in susceptible individuals.
To ensure safety and effectiveness, regular monitoring is required during treatment including:
You have the right to discuss and consider alternative treatments with your healthcare provider. These alternatives may include:
As a patient, you are responsible for:
I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
By selecting below, you confirm that you:
Identity Verification
Upload a photo of a valid government-issued photo ID such as a driver’s license or passport which has your picture, name and date of birth clearly visible. If applicable, upload a photo of the front and the back especially when using a military ID as your date of birth is on the back of the card. Make sure the photo is clear and legible.
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