First Name

Last Name

Phone *

Email *

Have you ever taken peptides (e.g., Sermorelin, NAD+, BPC-157, GHK-Cu, CJC-1295, Ipamorelin, TB-500, or Glutathione) and had a reaction?

Yes

Are you pregnant, planning pregnancy, or breastfeeding?

Yes

Have you ever been diagnosed with kidney or liver disease?

Yes

Which peptide(s) are you interested in?

BPC-157 Injection

Have you been diagnosed with ANY form of active cancer or malignancy?

a. No, I have NOT been diagnosed with or suspect any form of active cancer or malignancy.

b. Yes, I have been diagnosed with or suspect an active cancer or malignancy.

Do you have an active autoimmune flare-up or a history of systemic inflammatory disease?

a. No, I am NOT currently experiencing an autoimmune flare-up.

b. Yes, I have a history of autoimmune or systemic inflammatory disease.

Are you currently pregnant, planning to become pregnant, or breastfeeding?

a. No, I am NOT currently pregnant, trying to become pregnant, or breastfeeding.

b. Yes, I am currently pregnant, trying to become pregnant, or breastfeeding.

Do you have a known allergy or hypersensitivity to BPC-157 or its components?

a. No, I have NO known history of allergic reactions to BPC-157.

b. Yes, I have a known allergy or hypersensitivity to BPC-157.

Are you aware that BPC-157 is a research peptide and is NOT FDA approved for human use or the treatment of any specific medical condition?

a. Yes, I am aware of this status and wish to proceed.

b. No, I was not aware and/or have concerns.

BPC-157 Oral

Have you been diagnosed with ANY form of active cancer, or do you have a personal history of malignancy (even if in remission)?

a. No, I have NOT been diagnosed with or suspect any form of cancer.

b. Yes, I have a history of cancer or an active diagnosis.

Note: BPC-157 promotes angiogenesis (new blood vessel growth). While this is beneficial for healing, it may theoretically facilitate the growth or spread of existing tumors.

Do you have a history of inflammatory bowel disease (Crohn's or Ulcerative Colitis), Celiac disease, or stomach ulcers?

a. No, I do NOT have a history of these gastrointestinal conditions.

b. Yes, I have a history of a chronic gastrointestinal disorder.

Note: While often used to support gut health, patients with active flares should consult their specialist before beginning new protocols.

Are you a competitive athlete subject to drug testing by WADA, USADA, or the NCAA?

a. No, I am NOT a competitive athlete subject to these regulations.

b. Yes, I am a competitive athlete and understand BPC-157 is a prohibited substance.

Note: BPC-157 is strictly prohibited at all times by the World Anti-Doping Agency (Category S0) and most athletic governing bodies.

Do you have a history of autoimmune disease or a compromised immune system?

a. No, I do NOT have a history of autoimmune or immune system disorders.

b. Yes, I have a history of autoimmune issues or immune system disorders.

Note: The FDA has noted potential risks of immunogenicity (immune system reactions) associated with BPC-157.

Are you currently pregnant, planning to become pregnant, or breastfeeding?

a. No, I am NOT pregnant, planning to become pregnant, or breastfeeding.

b. Yes, I am currently pregnant, planning to become pregnant, or breastfeeding.

Note: The safety of BPC-157 has not been established for pregnant or nursing mothers.

Are you aware that BPC-157 is considered a "Category 2" substance by the FDA, is NOT FDA-approved for human use, and is NOT intended to diagnose, treat, cure, or prevent any disease?

a. Yes, I am aware of this status and wish to proceed.

b. No, I was not aware and/or have concerns.

NAD+

Have you been diagnosed with ANY form of active cancer or malignancy?

a. No, I have NOT been diagnosed with or suspect any form of active cancer or malignancy.

b. Yes, I have been diagnosed with or suspect an active cancer or malignancy.

Note: Because NAD+ supports cellular repair and energy, its use in active cancer is a subject of ongoing clinical debate regarding the fueling of rapidly dividing cancer cells.

Do you have a known history of "over-methylation," or have you experienced significant anxiety/jitters when taking high doses of B-vitamins (like Niacin or B12)?

a. No, I do NOT have a history of sensitivity to B-vitamins or methylation issues.

b. Yes, I have a history of sensitivity or known methylation disorders.

Do you have a history of Gout or chronically high levels of Uric Acid?

a. No, I do NOT have a history of Gout.

b. Yes, I have a history of Gout or elevated Uric Acid levels.

Note: NAD+ metabolism involves pathways that can occasionally influence uric acid levels in sensitive individuals.

Are you currently pregnant, planning to become pregnant, or breastfeeding?

a. No, I am NOT currently pregnant, planning to become pregnant or breastfeeding.

b. Yes, I am currently pregnant, planning to become pregnant or breastfeeding.

Do you have a known allergy or hypersensitivity to NAD+, Nicotinamide, Niacin, or any components of the injectable preparation?

a. No, I have NO known history of allergic reactions to NAD+ or related compounds.

b. Yes, I have a known allergy or hypersensitivity to NAD+ or its components.

Are you aware that NAD+ peptide therapy is considered a research-based nutritional/cellular intervention and is NOT FDA approved to prevent, treat, or cure any specific disease?

a. Yes, I am aware that NAD+ is not FDA approved for these uses and I wish to proceed.

b. No, I was not aware of this status and/or I have concerns regarding its use.

Glutathione

Do you have a known allergy or sensitivity to sulfa drugs or sulfur-containing foods/supplements?

a. No, I have NOT experienced any allergic reactions to sulfur or sulfa-based medications.

b. Yes, I have a known allergy or sensitivity to sulfur or sulfa-based medications.

Do you have a history of asthma or any chronic respiratory conditions?

a. No, I do NOT have a history of asthma or respiratory disease.

b. Yes, I have a history of asthma or a chronic respiratory condition.

Do you have any known history of significant kidney (renal) or liver (hepatic) impairment?

a. No, I do NOT have a history of kidney or liver disease.

b. Yes, I have been diagnosed with or treated for kidney or liver disease.

Are you currently pregnant, planning to become pregnant, or breastfeeding?

a. No, I am NOT currently pregnant, trying to become pregnant, or breastfeeding.

b. Yes, I am currently pregnant, trying to become pregnant, or breastfeeding.

Are you aware that Glutathione injections are NOT FDA approved to treat, prevent, or cure any specific medical condition?

a. Yes, I am aware of this status and wish to proceed.

b. No, I was not aware and/or have concerns.

Sermorelin

Have you been diagnosed with ANY form of active cancer or malignancy?

a. No, I have NOT been diagnosed with or suspect any form of active cancer or malignancy.

b. Yes, I have been diagnosed with or suspect an active cancer or malignancy.

Do you have a known history of structural pituitary or hypothalamic disease (such as tumors, prior brain surgery, or radiation)?

a. No, I do NOT have a history of hypothalamic or pituitary pathology.

b. Yes, I have a history of structural hypothalamic or pituitary disease.

Are you currently experiencing a major acute illness, or are you currently recovering from a major surgery or physical trauma?

a. No, I am NOT currently experiencing an acute critical illness.

b. Yes, I am currently experiencing or recovering from an acute critical illness.

Are you currently pregnant, planning to become pregnant, or breastfeeding?

a. No, I am NOT currently pregnant, trying to become pregnant, or breastfeeding.

b. Yes, I am currently pregnant, trying to become pregnant, or breastfeeding.

Do you have a known allergy or hypersensitivity to Sermorelin or any of its specific components?

a. No, I have NO known history of allergic reactions to Sermorelin.

b. Yes, I have a known allergy or hypersensitivity to Sermorelin or its components.

Are you aware that Sermorelin is a research peptide and is NOT FDA approved for the treatment of adult growth hormone deficiency or anti-aging purposes?

a. Yes, I am aware of this status and wish to proceed.

b. No, I was not aware and/or have concerns.

CJC-1295 / Ipamorelin

Have you been diagnosed with ANY form of active cancer, or do you have a personal history of malignancy (even if in remission)?

a. No, I have NOT been diagnosed with or suspect any form of cancer.

b. Yes, I have a history of cancer or an active diagnosis.

Note: Growth hormone secretagogues may accelerate the growth of existing tumors or increase the risk of recurrence.

Do you have a history of Type 1 or Type 2 Diabetes, or impaired glucose tolerance (prediabetes)?

a. No, I do NOT have a history of diabetes or high blood sugar.

b. Yes, I have a history of diabetes or glucose intolerance.

Note: These peptides can increase blood sugar and decrease insulin sensitivity.

Do you have a history of pituitary gland tumors, pituitary surgery, head radiation, or severe head trauma?

a. No, I do NOT have a history of pituitary disorders or major head trauma/radiation.

b. Yes, I have a history of pituitary issues or head trauma/radiation.

Do you have a history of heart failure, high blood pressure, or significant fluid retention (edema)?

a. No, I do NOT have a history of these cardiovascular issues.

b. Yes, I have a history of heart issues or significant swelling/edema.

Do you suffer from untreated Sleep Apnea or Carpal Tunnel Syndrome?

a. No, I do NOT suffer from sleep apnea or carpal tunnel.

b. Yes, I have sleep apnea or carpal tunnel syndrome.

Note: Increased growth hormone can lead to fluid shifts that may aggravate these conditions.

Are you currently pregnant, planning to become pregnant, or breastfeeding?

a. No, I am NOT pregnant, planning to become pregnant, or breastfeeding.

b. Yes, I am currently pregnant, planning to become pregnant, or breastfeeding.

Are you aware that CJC-1295 and Ipamorelin for off-label use are NOT FDA-approved for anti-aging and are NOT intended to diagnose, treat, cure, or prevent any disease?

a. Yes, I am aware of this status and wish to proceed.

b. No, I was not aware and/or have concerns.

GHK-Cu Injection

Do you have a history of Wilson's Disease or any other disorder related to copper metabolism/sequestration?

a. No, I do NOT have a history of copper metabolism disorders.

b. Yes, I have a history of Wilson's Disease or copper-related health issues.

Are you currently being treated for a severe Zinc deficiency?

a. No, I am NOT currently treated for Zinc deficiency.

b. Yes, I am.

Note: High copper intake can further deplete zinc levels.

Are you currently pregnant, planning to become pregnant, or breastfeeding?

a. No, I am NOT currently pregnant, trying to become pregnant, or breastfeeding.

b. Yes, I am currently pregnant, trying to become pregnant, or breastfeeding.

Do you have a known allergy or hypersensitivity to Copper-Peptides or the injection site components?

a. No, I have NO known history of allergic reactions to GHK-Cu.

b. Yes, I have a known allergy or hypersensitivity to GHK-Cu.

Are you aware that GHK-Cu injections are considered research-based and are NOT FDA approved for systemic use?

a. Yes, I am aware of this status and wish to proceed.

b. No, I was not aware and/or have concerns.

Wolverine Blend (BPC-157 / TB-500)

Have you been diagnosed with ANY form of active cancer, or do you have a personal history of malignancy (even if in remission)?

a. No, I have NOT been diagnosed with or suspect any form of cancer.

b. Yes, I have a history of cancer or an active diagnosis.

Note: Both BPC-157 and TB-500 promote angiogenesis (new blood vessel growth). While this helps heal injuries, it could theoretically stimulate the growth or spread of existing tumors.

Do you have a history of proliferative retinopathy, wet macular degeneration, or any condition involving abnormal blood vessel growth in the eye?

a. No, I do NOT have a history of these ocular conditions.

b. Yes, I have a history of proliferative eye disease.

Are you a competitive athlete subject to drug testing by WADA, USADA, or the NCAA?

a. No, I am NOT a competitive athlete subject to these regulations.

b. Yes, I am a competitive athlete and understand these substances are prohibited.

Note: Both BPC-157 and TB-500 are strictly prohibited at all times by the World Anti-Doping Agency (Category S0).

Are you currently pregnant, planning to become pregnant, or breastfeeding?

a. No, I am NOT pregnant, planning to become pregnant, or breastfeeding.

b. Yes, I am currently pregnant, planning to become pregnant, or breastfeeding.

Note: The safety of these peptides has not been established for pregnant or nursing mothers.

Do you have a history of autoimmune disease or a compromised immune system?

a. No, I do NOT have a history of autoimmune or immune system disorders.

b. Yes, I have a history of autoimmune issues or immune system disorders.

Note: The FDA has noted potential risks of immunogenicity (immune system reactions) with compounded BPC-157.

Are you currently experiencing an acute infection, fever, or severe systemic illness?

a. No, I am NOT currently suffering from an acute infection or illness.

b. Yes, I currently have an infection or illness.

Do you have a history of congestive heart failure or severe cardiovascular disease?

a. No, I do NOT have a history of severe cardiovascular disease.

b. Yes, I have a history of heart failure or cardiovascular disease.

Are you aware that BPC-157 and TB-500 are considered experimental "Category 2" substances by the FDA, are NOT FDA-approved for human use, and are NOT intended to diagnose, treat, cure, or prevent any disease?

a. Yes, I am aware of this status and wish to proceed.

b. No, I was not aware and/or have concerns.

Glow Blend (GHK-Cu / BPC-157 / TB-500)

Have you been diagnosed with ANY form of active cancer or malignancy, or do you have a personal history of cancer (even if currently in remission)?

a. No, I have NOT been diagnosed with or suspect any form of active cancer or malignancy.

b. Yes, I have been diagnosed with or suspect an active cancer or malignancy.

Note: Because BPC-157, TB-500, and GHK-Cu promote angiogenesis (the formation of new blood vessels) and cellular migration, they could theoretically facilitate the growth or spread of existing tumors.

Do you have a history of proliferative retinopathy, wet macular degeneration, or any condition involving abnormal blood vessel growth in the eye?

a. No, I do NOT have a history of these ocular conditions.

b. Yes, I have a history of proliferative eye disease.

Note: The angiogenic properties of these peptides may aggravate conditions characterized by abnormal blood vessel proliferation.

Do you have a history of autoimmune disease or a compromised immune system?

a. No, I do NOT have a history of autoimmune or immune system disorders.

b. Yes, I have a history of autoimmune issues or immune system disorders.

Note: There is a potential risk of immunogenicity (immune system reactions) associated with certain compounded peptides.

Are you currently pregnant, planning to become pregnant, or breastfeeding?

a. No, I am NOT pregnant, planning to become pregnant, or breastfeeding.

b. Yes, I am currently pregnant, planning to become pregnant, or breastfeeding.

Note: The safety profile of these peptides has not been established for pregnant or nursing mothers.

Are you a competitive athlete subject to drug testing by WADA, USADA, or the NCAA?

a. No, I am NOT a competitive athlete subject to these regulations.

b. Yes, I am a competitive athlete and understand these substances are prohibited.

Note: BPC-157 and TB-500 are strictly prohibited at all times by the World Anti-Doping Agency (Category S0).

Do you have a history of congestive heart failure or severe cardiovascular disease?

a. No, I do NOT have a history of severe cardiovascular disease.

b. Yes, I have a history of heart failure or cardiovascular disease.

Are you aware that the Glow Blend (GHK-Cu, BPC-157, TB-500) consists of investigational peptides, is NOT FDA-approved for human use, and is NOT intended to diagnose, treat, cure, or prevent any disease?

a. Yes, I am aware of this status and wish to proceed.

b. No, I was not aware and/or have concerns.

MIC Injection (Lipo-B)

Are you allergic to sulfur or "sulfa" drugs (e.g., Bactrim, Septra, or certain diuretics)?

a. No, I do NOT have an allergy to sulfur or sulfa medications.

b. Yes, I have a known allergy to sulfur or sulfa medications.

Note: Methionine, a primary ingredient in MIC, contains sulfur.

Do you have a history of chronic kidney disease, kidney failure, or severe liver impairment (such as cirrhosis)?

a. No, I do NOT have a history of kidney or severe liver disease.

b. Yes, I have a history of kidney or liver disease.

Are you currently pregnant or breastfeeding?

a. No, I am NOT pregnant or breastfeeding.

b. Yes, I am currently pregnant or breastfeeding.

Do you have a history of gout or frequent kidney stones?

a. No, I do NOT have a history of gout or kidney stones.

b. Yes, I have a history of gout or frequent kidney stones.

Note: High doses of certain nutrients can occasionally trigger these conditions in predisposed individuals.

Have you ever had an adverse or allergic reaction to Vitamin B12 (Cyanocobalamin or Methylcobalamin) or Cobalt?

a. No, I have NOT had a reaction to Vitamin B12 or Cobalt.

b. Yes, I have a known sensitivity to Vitamin B12 or Cobalt.

Are you aware that MIC injections for weight management are often used off-label and are NOT intended to diagnose, treat, cure, or prevent any disease?

a. Yes, I am aware of this status and wish to proceed.

b. No, I was not aware and/or have concerns.

Please review and agree to the following before proceeding:

By checking this box, I consent to the use of peptides as part of my treatment plan. *

I, the undersigned, acknowledge the regulatory status of the peptide(s) I have selected as previously stated. In electing to proceed with this treatment, I agree to the following: Assumption of Risk: I understand that while these peptides are used for their potential therapeutic properties, clinical data may be limited. I voluntarily assume all risks associated with the use of these peptides, including both expected and unexpected physiological outcomes or side effects. Release of Liability: I hereby release, indemnify, and hold harmless AMS Lifestyle Medicine & its providers, prescribers, its staff, and its affiliates from any and all liability, claims, or causes of action arising out of my use of this treatment. Accuracy of Information: I certify that the medical history provided above is true and accurate. No Guarantee of Results: I acknowledge that no guarantees have been made regarding the specific results or outcomes of peptide therapy.

I have read and understand the Clinical Guidance Disclaimer. *

The information provided in this document is for educational and informational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. It should never replace sound clinical judgment or personalized advice of a qualified healthcare professional. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or treatment protocol. Never disregard professional medical advice or delay in seeking it because of something you have read in these materials.

I have read and understand the Liability & Indemnification statement. *

By utilizing this information, the user acknowledges and agrees that AMS Lifestyle Medicine and its affiliates, providers, and staff are not liable for any direct, indirect, or consequential damages resulting from the use or misuse of the information provided herein. Any reliance on the materials contained in this document is solely at the user's own risk.

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