Peptide Therapy Intake | Lavena Health

Step 1 of 6

Patient Information

Please complete all fields accurately. This information is used to coordinate your peptide therapy care.

Personal Details

First Name *

Last Name *

Date of Birth *

Biological Sex *

State *

Email *

Phone *

Street Address *

City *

ZIP Code *

Height

Weight (lbs)

BMI (auto)

How did you hear about us?

If referred by someone, please share their name (optional)

Step 6 of 6

Informed Consent & Signature

Please read carefully. Your electronic signature is legally binding under Florida Statute §668.50.

Informed Consent for Peptide Therapy

Nature of Treatment

I am consenting to receive peptide therapy prescribed by a licensed Florida physician through Lavena Health. Peptides are short chains of amino acids that act as signaling molecules in the body. Common peptides used include BPC-157, CJC-1295, Ipamorelin, TB-500, PT-141, Semax, Selank, and others as clinically indicated. Administration may be subcutaneous injection, oral, nasal, or topical as determined by my provider.

Off-Label & Research Status

I understand that peptide therapy is not FDA-approved for the specific indications for which it is being used. Most research peptides are used off-label based on preclinical data and emerging human studies. Compounded peptides are prepared by licensed compounding pharmacies and have not undergone FDA pre-market review. I accept this as part of my informed decision to proceed with treatment.

Potential Benefits

Accelerated tissue and injury healing (BPC-157, TB-500)
Improved growth hormone secretion, muscle gain, fat loss, and anti-aging (CJC-1295, Ipamorelin)
Enhanced sexual function and libido (PT-141)
Cognitive enhancement, mood, and neuroprotection (Semax, Selank)
Reduced inflammation and immune modulation
Improved sleep quality and recovery

Individual results vary. Many benefits are supported by preclinical and early-phase human data.

Risks & Side Effects

Injection site reactions — redness, bruising, or discomfort at the injection site
Nausea, flushing, or transient headache — particularly with GH secretagogues
Water retention or facial flushing — with CJC-1295/Ipamorelin stacks
Increased hunger — common with Ipamorelin and GH secretagogues
Temporary skin flushing or nausea — with PT-141
Theoretical cancer risk with long-term GH-stimulating peptides — use with caution if personal/family history of cancer
Unknown long-term safety profile — long-term human data is limited for many peptides
Rare allergic reaction — discontinue and seek care if rash, swelling, or difficulty breathing occurs

Patient Responsibilities

I will store all peptides as directed (typically refrigerated) and use sterile injection technique
I will report any adverse reactions to my provider promptly
I will complete requested baseline and follow-up laboratory testing
I will inform my provider of any changes in medications or health status

Direct-Pay & Truthfulness

I certify that all information in this intake is truthful and complete to the best of my knowledge. I understand that Lavena Health is a cash-pay clinic and no insurance is billed. Transparent pricing will be discussed before any prescription is issued. I may withdraw consent at any time without affecting my access to other services.

Identity Verification

Why we ask: Florida law and federal telehealth regulations require that prescribing physicians verify patient identity before issuing prescriptions. Your attestation below satisfies this requirement for your initial intake. A government-issued photo ID may be requested at or before your first consultation.

I attest that I am the person named in this intake form and that all personal information provided (name, date of birth, address) is accurate and truthful.

I understand that a valid government-issued photo ID (driver's license, passport, or state ID) may be requested before my prescription is issued, and I agree to provide one upon request.

I confirm that I am a resident of the state selected in this form and am physically located within that state at the time of this consultation request.

Date of Birth (re-enter to confirm identity)

Acknowledgments & Signature

I have read and understood the nature, risks, and benefits of peptide therapy as described above.

I understand that peptide therapy is off-label and not FDA-approved for these indications, and I accept this as part of my decision to proceed.

I agree to complete any required baseline or follow-up laboratory testing as requested by my provider.

I confirm I am 18 years of age or older, am the patient named in this form, and voluntarily consent to peptide therapy through Lavena Health. All information provided is truthful and complete.

Full Legal Name *

Or type your full legal name as your electronic signature

Today's Date *

Electronic Signature Notice: By typing your full legal name above and clicking Submit, you are providing a legally binding electronic signature under Florida Statute §668.50 and the federal E-SIGN Act (15 U.S.C. § 7001). This constitutes your informed consent to peptide therapy through Lavena Health.

ID Verification — Optional but recommended

Upload a photo of your government-issued ID to verify your identity. This helps your physician review your file faster.

📷 Tap to photograph ID or upload a file JPEG, PNG or PDF · Max 6MB · Encrypted & HIPAA secure

Patient Information

Medical History

Medications & Current Therapy

Treatment Goals & Lifestyle

Lab Work & Health Markers

Informed Consent & Signature