La Flaca Consents

I seek medical help from Lev Paukman, MD and Manhasset Med Spa. I am executing this consent to confirm my discussion with Lev Paukman, MD, and my understanding of the risks, benefits, and alternatives to treatment with Peptides. The goal and possible benefits of this therapy are to try and prevent, reduce or control the dysfunction associated with the aging process through hormonal balancing, control of oxidative stress, and other clinically significant therapeutic agents. However, I understand that this treatment may be viewed by the mainstream medical community as new, controversial, and unnecessary by the Food and Drug Administration (“FDA”).

Benefits and General Information

Peptides are a selective ghrelin secretagogue which also encourages endogenous growth hormone release. Peptides are synergistic to increase serum growth hormone levels and thereby increase serum levels of IGF1 and IGFBP3.

Risks

The following are examples of some of the possible specific risks/adverse reactions reported for therapy that may be prescribed for me. Some of these risks/adverse reactions are for prescription drugs derived from the official FDA labeling requirements for these drugs. At physiological blood levels, there are not expected to be any significant risks/adverse reactions as long as full medical disclosure is achieved from the patient during the total time of therapy.

By signing this form, I understand the possible risks associated with this treatment. For Peptides, adverse reactions include injection site redness, transient high blood sugar, development of antibodies, and water retention. These side effects are dose-related and usually eliminated by adjusting the dosage. This drug should not be used in patients with known cancer.

I understand that Lev Paukman, MD, will monitor my treatment in an effort to prevent any side effects, but cannot guarantee that I will not experience any side effects or adverse reactions. I understand that, as with any health treatment, there is no guarantee I will obtain satisfactory results through the use of this therapy. I understand the use of this treatment does not preclude me from using other treatments as well. However, I recognize that I should inform any practitioners I am seeing about the various treatments I am using.

NOTE: DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND FEEL THAT YOU UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE BEFORE SIGNING THIS FORM. DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR MENTAL ABILITIES OR IF YOU FEEL RUSHED OR UNDER PRESSURE.