Peptide Therapy Informed Consent -

Please read this consent carefully. It explains the nature of peptide therapy, its potential benefits, risks, and alternatives so you can make an informed decision. Ask Dr. Thomas any questions before signing.

This signed consent is sent to Dr. Thomas’s clinical team by email. It does not begin treatment — peptides are prescribed only after your consultation and at the provider’s clinical discretion.

Nature of Peptide Therapy

Peptides are short chains of amino acids that act as signaling molecules in the body. In peptide therapy, specific peptides are prescribed to support goals such as tissue recovery, metabolism and weight management, growth-hormone signaling, immune function, sleep, or sexual health. Peptides may be administered by subcutaneous injection, orally, or topically, depending on the specific agent and your protocol.

Your treatment plan is individualized. Dr. Thomas will select agents, dosing, and duration based on your history, goals, and any laboratory testing, and may adjust or discontinue therapy over time.

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Peptide Therapy Interest

Depending on the peptide and your individual response, potential benefits may include:

Improved tissue repair, recovery, or joint comfort
Support for weight management and body composition
Improved energy, sleep quality, or cognitive clarity
Support for immune function or sexual health

No specific result is guaranteed. Individual responses vary, and some patients experience little or no benefit.

Risks and Possible Side Effects

As with any medical therapy, peptide treatment carries risks. Possible side effects include, but are not limited to:

Injection-site reactions such as redness, swelling, bruising, or pain
Nausea, headache, fatigue, dizziness, or flushing
Changes in appetite, blood sugar, water retention, or blood pressure
Allergic or hypersensitivity reactions, which in rare cases can be serious
Effects specific to the prescribed agent, which your provider will review with you

Because many peptides are relatively new, their long-term risks are not fully established, and not all peptides are FDA-approved. You should report any new or worsening symptoms to the office promptly.

Off-Label and Compounded Medications

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Some peptides are used off-label (for uses not specifically approved by the FDA) and may be compounded by a licensed pharmacy rather than manufactured commercially. Off-label prescribing is legal and common in medical practice when supported by clinical judgment.

You understand that certain peptides recommended to you may not be FDA-approved for your specific use, and that Dr. Thomas has discussed, or will discuss, the reasons these agents are being recommended.

Alternatives to Treatment

Alternatives to peptide therapy include no treatment, lifestyle and nutritional changes, other medications or supplements, and conventional therapies appropriate to your condition. You have the right to decline peptide therapy or to stop at any time, and doing so will not affect your ability to receive other care at Sure Success Wellness Center.

Financial Acknowledgment

Sure Success Wellness Center is a functional medicine practice and does not bill insurance. Peptide therapy, related consultations, laboratory testing, and medications are self-pay. Fees will be reviewed with you, and payment is your responsibility.

Acknowledgment and Consent

I have read and understand this consent, including the nature, benefits, risks, and alternatives of peptide therapy.
I have had the opportunity to ask questions, and any questions I have will be answered before treatment begins.
I understand that results are not guaranteed and that individual responses vary.
I understand that some peptides may be off-label and/or compounded, and I consent to their use as recommended.
I understand that peptide therapy is self-pay and that insurance will not be billed.
I understand I may withdraw my consent and stop treatment at any time.
I confirm the information I have provided is accurate to the best of my knowledge, and I voluntarily consent to peptide therapy.

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