Peptide Consent Form

Peptide Consent Form

I hereby request and consent to examination and subcutaneous and or intramuscular injection of vitamins and peptides as well as treatment with naturopathic care, including various modes of physical therapy, elective vitamin and peptide injection and bioidentical hormone replacement therapy for me (or for the patient named below, for whom I have legal authority to act) by Ricardo Paneque  APRN (“Provider”).

Naturopathic evaluation includes commonly used physical examination methods and movements to test with positions and progression of forces on the bones, joints, muscles and other tissues and organs to help to determine the diagnosis and course of treatment.

I understand that I am in full control of my body during the examination and it is my responsibility to inform the healthcare provider of any procedure that I feel may cause injury or that I want to be stopped. I, as a patient, have a right to be informed about my condition and recommended care. This disclosure is to help me become better informed so I may make the decision to give or withhold my consent to any proposed treatment.

I understand that naturopathic evaluation and treatment may include, but is not limited to, various modes of physical therapy (ultrasound, trigger point therapy, reflexology, hydrotherapy, heat, cold, traction, stretching, exercise, spinal manipulation, Bowen, Reiki, essential oils, bioidentical hormones replacement, subcutaneous and or intramuscular injection of vitamins minerals and peptides etc.), collecting specimens for laboratory evaluation, including blood draws and/or ordering diagnostic imaging and tests, prescription of certain medications and nutritional supplements, counseling and dietary therapy, homeopathic medicines referred to as “remedies.”  I understand the U.S. Food and Drug Administration (“FDA”) has not evaluated or approved nutritional, herbal and homeopathic supplements; however, they have been widely used in Europe and the United States for many years. Further, I understand that certain treatments or remedies that will be used to treat me are considered “off-label” by the FDA and the potential risks and complications for such off-label use are difficult to predict. Off-label refers to the use of, relating to or being an approved drug legally prescribed for a purpose for which it has not been specifically approved. I also understand that, as with drugs, nutritional supplements, vitamin injection, bioidentical hormone replacement, herbal and homeopathic remedies may cause some side effects in certain individuals, may interact with certain allopathic medications or lab tests, or show symptoms due to certain pre-existing conditions.  I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment in recommending treatments that the doctor feels at the time, based on the facts then known, are in my best interest.

I have had the opportunity to ask questions and discuss with Ricardo Paneque APRN to my satisfaction the following:

  1. My suspected diagnosis or condition
  2. Treatment options and reasonably available alternatives
  3. The nature, purpose and potential benefit of the proposed care
  4. The inherent and possible risks, complications, and/or side effects of the treatment
  5. The probability or likelihood of success
  6. Recommended follow-up care
  7. The possible consequences if treatment or advice is not followed and/or nothing is done.

I understand and I am informed that in the practice of naturopathy, there are some risks of examination and treatment. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment. By signing below, I acknowledge I have read or have had read to me and understand the above consent. I consent to care and hereby relieve Ricardo Paneque, APRN and Vive Concierge Health, Inc. (“Vive”) of any legal responsibility regarding side effects or complications that may occur due to receiving the aforementioned treatments or remedies. I understand that Vive has elected not to carry medical malpractice insurance but Provider carries adequate medical malpractice insurance, in accordance with Florida law, to maintain Provider’s Florida license and to satisfy any adverse judgments or any other financial responsibility related to the payment of claims and costs ancillary thereto arising out of the rendering of, or the failure to render, medical care or services.

By signing this Consent I confirm That I nor Anyone in My Family Has Had or Been diagnosed with

  • Medullary Thyroid Carcinoma
  • Multiple Endocrine Neoplasia Syndrome Type 2
  • Currently Have Or Have Had Pancreatitis
  • Have An Allergy To Semaglutide or Tirzepatide.

I certify that if any concerns or side effects occur, I will promptly notify Ricardo Paneque or the appropriate Vive representative. I also understand that Mr. Paneque  and Vive are not responsible for any manufacturing issues related to these treatments ore remedies, such as sterility and potency, which are the sole responsibility of the compounding pharmacy preparing them. I intend this consent form to cover the entire course of treatment for my present condition and for any condition(s) for which I seek treatment in the future.

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY