Terms of Agreement and Consent for Treatment

DISCLAIMER

Individual results vary. Best results obtained with combination of a healthy diet and lifestyle. These products nor the ingredients have been approved or endorsed by the FDA. These products are not intended to diagnose, treat, cure or prevent any disease. Homeopathic products have not been reviewed by the FDA for safety and effectiveness to diagnose, treat, cure, or prevent any disease or conditions. These are compounded for human use by a US 503A compounding pharmacy that provides these on patient-specific use as a dietary supplement. You should consult a licensed health care professional before starting any supplement, dietary, or exercise program. Products not recommended if you are pregnant or breast feeding.

Consent of Treatment

I understand that, as with any health treatment, there is no guarantee that I will obtain satisfactory results. If I am being treated for a medical condition, or have symptoms which suggest a medical condition may be present, I have been informed that it is in my best interest to discuss potential alternative methods of treatment for my condition with my primary care physician or an appropriate specialist before as well as during the course of treatments. I understand the use of this procedure does not preclude me from using other treatments as well, though I recognize that I should inform any practitioners I am seeing about the various treatments I am using.

I understand and agree that all services rendered to me are charged directly to me and that I am personally and financially responsible for payment at time of service. I understand that peptide treatment is a cash service and not covered by insurance and agree to not submit to my insurance for reimbursement/coverage or expect AMWM to submit rendered services to insurance for coverage or reimbursement. Peptides are FSA and HSA approved. I further agree that all sales are final and there are no refunds or returns on any purchased products.

I hereby consent to peptide treatment and certify that I understand the nature of this treatment, including the risks of possible complications and choices I may have about other approaches, and assume those risks about which I have been informed I represent that I am seeking treatment in order to further my own health and for no other reason and do not represent a third party. I am aware that I may withdraw this consent and stop treatment at any time.

By clicking consent of treatment, I acknowledge that I have read the foregoing informed consent/ risks of treatment and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent treatments with the above understood. I hereby release Age Management of West Michigan and its physicians and staff from liability and medical-legal responsibility associated with this treatment.

BPC 157 Risks and Side effects: There are no documented side effects of BPC 157 therapy. There are no known drug interactions with BPC 157. BPC 157 is not recommended if your pregnant or breast feeding.

TB500 Risks and Side effects: There are no documented side effects of TB500 therapy. There are no known drug interactions with TB500. TB500 is not recommended if your pregnant or breast feeding.

AOD9604 Risks and Side effects: There are no known health risks associated with the use of AOD 9604 Peptide Therapy. AOD 9604 is approved for GRAS status by the FDA. AOD9604 can be used in conjunction with other weight loss, hormone, and peptide therapies. AOD9604 is not recommended if your pregnant or breast feeding.

KPV Risks and Side effects: Research shows that KPV has an excellent safety profile with no documented side effects. KPV is not recommended if your pregnant or breast feeding.

Nootropic Brain Spray Risks and Side effects: Selank has a high safety profile and is practically non-toxic since it breaks down in the body into amino acids. Selank has been recommended by Russian and Ukraine doctors for more than a decade and is available in Russia as an OTC medication, available without prescription. Numerous clinical trials confirmed the safety of this peptide, which was found to not form a dependence and to be non-toxic even in doses 200-500 times higher than the therapeutic ones. Selank does not cause drowsiness, lethargy, dull thinking, and other side effects associated with most medications used to treat neurological and mental disorders. Selank does not cause addiction or withdrawal symptoms. Selank is compatible to be used with various medications to treat cognitive and neurological disorders. Selank has a positive effect when utilized in combination with other medications by alleviating withdrawal symptoms and reducing side effects. Selank can be safely utilized along with consumption of alcohol and helps offset the toxicity of alcohol on brain function. Semax is very well-tolerated by most users, with few reported side effects. However, some users experience a slight burning sensation in the nasal passages or mild mucus membrane irritation after administration. Most reported side effects are mild and transient.: Headaches, nausea, vomiting, drowsiness, and hair loss (Increased BDNF levels can promote hair loss inpatients prone to baldness. Oxytocin side effects are very uncommon. There have been some side effects associated with the use of this drug wherein the patient had one of the issues listed below at some point while being on oxytocin. However, these side effects weren’t confirmed to be associated with the treatment and could have been a coincidence and not related to the use of oxytocin. Despite this, it was listed as a side effect associated with oxytocin even though these associated side effects are very uncommon. Side effects associated with oxytocin may include the following: Blurred vision, confusion, increased blood pressure, loss of appetite, nausea, stomach pain, and vomiting. Nootropic Brain Spray is not recommended if your pregnant or breast feeding.

Bremelanotide (PT 141) Side Effects: Heart rate reduction, increased blood pressure, nausea, vomiting, flushing, cough, stuffy nose, headache, and focal hyperpigmentation. Bremelanotide (PT 141) is not recommended for the following people or conditions: Cardiovascular disease and heart disease (recommend physician approval), uncontrolled Hypertension, kidney disease, liver disease, and pregnant or breast feeding. Bremelanotide (PT 141) is not recommended to be used with the following medications: Naltrexone and Indomethacin. PT141 decreases gastric emptying and has been shown to decrease the rate and extent of absorption of other orally administered drugs. Use caution with antibiotics and pain medications.

D-SIP Risks and Side effects: Side effects of D-SIP may include headaches, dizziness, nausea, and stomach pain. Side effects are typically mild and subside independently without intervention. D-Sip is not recommended if your pregnant or breast feeding.

Nutrient Injection Consent of Treatment:

I understand that vitamins, minerals, and amino acids are essential for our body’s normal function, growth, repair, and overall well-being. Except for a few exceptions, vitamins, minerals, and amino acids cannot be manufactured or synthesized by the body and need to be obtained through diet and or supplemental form. Deficiencies in the body can result in specific physiological symptoms and diseases. Latest research indicates that vitamins, minerals, and amino acids that are taken in therapeutic doses may stimulate a positive effect in a wide range of common symptoms and diseases. Nutrient injections provide a higher absorption of key amino acids, vitamins, and mineral nutrients by eliminating the mal-absorption issues that can occur through oral supplementation and the digestive system.

Risks

I understand that there are minor side effects that can occur from any injections that include but may not be limited to: mild diarrhea, upset stomach, nausea, a feeling of warmth or pain at injection site, headache, and joint pain. I understand that although rare, nutrient injections can result in serious side effects and allergic reactions. If any of these side effects occur I will immediately contact my primary care physician and discontinue further use of the product. Serious side effects may include but may not be limited to: Rapid heartbeat / chest pain / tightness, difficulty breathing / swallowing / shortness of breath / dizziness / confusion, and hives / rash / skin irritation.

I understand that nutrient injections can interact with medications and drug interactions could occur that could increase your risk of bleeding or block the absorption of nutrients in the body. Some of the medications that may cause drug interactions include, but are not limited to: Heparin, Antithrombin, Argatroban, Aspirin, NSAID’s, Dipyridamole, Bivalirudin, Plavix, and Warfarin (Coumadin). I understand that certain herbal products, vitamins, minerals, nutritional supplements, prescription, and non-prescription medications may result in side effects when they interact with Nutrient Injections.

I understand and agree that all services rendered to me are charged directly to me and that I am personally and financially responsible for payment at time of service. I understand that nutrient injections are not covered by insurance and agree to not submit to my insurance for reimbursement/coverage or expect AMWM to submit rendered services to insurance for coverage or reimbursement. I further agree that all sales are final and there are no refunds or returns on injections.

I hereby consent to nutrient injections therapy and certify that I understand the nature of this treatment, including the risks of possible complications and choices I may have about other approaches, and assume those risks about which I have been informed. I represent that I am seeking treatment in order to further my own health and for no other reason and do not represent a third party. I am aware that I may withdraw this consent and stop treatment at any time.

By clicking consent of treatment, I acknowledge that I have read the foregoing informed consent/ risks of treatment and agree to the treatment with its associated risks. I hereby give consent to perform this and all subsequent Nutrient Injections with the above understood. I hereby release Age Management of West Michigan and its physicians and staff from liability and medical-legal responsibility associated with this procedure.

Lipo B injections are not recommended for the following people or conditions: Pregnant or breast feeding, allergies to Methionine / Inositol / Choline, Acidosis, or individuals under 18 years of age.

Glutathione injections are not recommended for the following people or conditions: Pregnant or breast feeding, Chronic kidney failure and liver disease, undergoing severe asthmatic episodes, under current chemotherapy treatment (May decrease potency of anti-cancer drugs), or individuals under 18 years of age.

Pre-workout Amino injections are not recommended for the following people or conditions: Pregnant or breast feeding, using nitrates to treat cardiovascular disease, Hypertension medications, or ED drugs like sildenafil, tadalafil, or vardenafil (Combination of Pre-workout Amino injection could result in dangerous drop in blood pressure, chronic kidney failure or liver disease, or individuals under 18 years of age.

Vitamin C nutrient injections are not recommended for the following people or conditions: Pregnant or breast feeding, blood disorders like thalassemia, Hereditary hemorrhagic telangiectasis (HHT), G6PD deficiency, sickle cell disease, and hemochromatosis, or individuals under 18 years of age.

Methylated Vitamin B-12 injections are not recommended for the following people or conditions: Early hereditary optic nerve atrophy, B-12 hypersensitivity, pregnant or breast feeding, Kidney disease, Leber’s disease, Megaloblastic anemia, or individuals under 18 years of age.

Vitamin D injections are not recommended for the following people or conditions: Pregnant or breast feeding, Hypercalcemia, Hypervitaminosis D, Vitamin D hypersensitivity, Kidney / Renal disease or Renal failure, or individuals under 18 years of age.

Hair, Skin, and Nails nutrient injections are not recommended for the following people or conditions:

Early hereditary optic nerve atrophy, B-12 hypersensitivity, Pregnant or breast feeding, Kidney disease, Leber’s disease, Megaloblastic anemia, or individuals under 18 years of age.

Super Recovery Amino Blend nutrient injections are not recommended for the following people or conditions: Pregnant or breast feeding, Using nitrates to treat cardiovascular disease, Hypertension medications, or ED drugs like sildenafil, tadalafil, or vardenafil (Combination of Tri-Amino injection could result in dangerous drop in blood pressure, Chronic kidney failure or liver disease, Bipolar disorder: Glutamine may increase hypomania, Seizures: L-Glutamine and L-Carnitine may increase incidence of seizures in some people, patients using blood thinner medications, or individuals under 18 years of age.

CoQ10 Antioxidant injections are not recommended for the following people or conditions: Pregnant or breast feeding, may decrease effectiveness of some medications used for cancer. Some cancer medications include busulfan, carboplatin, cisplatin, cyclophosphamide, dacarbazine, thiotepa, and others. may decrease effectiveness of Warfarin and other blood thinning medications, may decrease blood pressure to low levels so use caution if on blood pressure medications, or individuals under 18 years of age.

Taurine injections are not recommended for the following people or conditions: Pregnant or breast feeding, patients using Lithium medications, or individuals under 18 years of age. May decrease blood pressure to low levels so use caution if on blood pressure medications.

Tri-Immune nutrient injections are not recommended for the following people or conditions: Pregnant or breast feeding, Chronic kidney failure and liver disease, undergoing severe asthmatic episodes, under current antibiotic or chemotherapy treatment (May decrease potency of anti-cancer drugs and antibiotic effectiveness), blood disorders like thalassemia, Hereditary hemorrhagic telangiectasis (HHT), G6PD deficiency, sickle cell disease, and hemochromatosis, or under 18 years of age. May decrease blood pressure to low levels so use caution if on blood pressure medications.

Age Management of West Michigan reserves the right to limit and/ or deny sales of products to any unqualified individuals. All customers must be 18 years of age to purchase our products. IN NO CIRCUMSTANCE SHALL AGE MANAGEMEN OF WEST MICHIGAN BE LIABLE FOR ICIDENTAL OR CONSEQUENTIAL DAMAGES, WHETHER PURCHASER’S CLAIM IN CONTRACT, NEGLIGENCE, STRICT LIABILITY OR OTHERWISE. IN DIRECT CONSIDERATION OF APPROVING THE SALE OF ANY PRODUCT TO THE PURCHASER AGREES TO INDEMNIFY AND HOLD AGE MANAGEMENT OF WEST MICHIGAN HARMLESS FROM ALL CLAIMS, EXPENSES, LOSSES AND LIABILITY OF ANY TYPE ARISING OUT OF THE PURCHASER’S HANDLING, POSSESSION, AND/OR USE OF THE PRODUCT, WHTHER USED ALONE OR IN COMBINATION WITH ANY SUBSTANCE. ANY SALE WOULD BE DENIED OTHERWISE.

ALL SALES ARE FINAL. No refunds or returns on products purchased. If products are received damaged, then Age Management of West Michigan must be notified within 24 hours of delivery along with pictures of damaged products and a detailed description. All damaged products will be reviewed for approval and replacement. Age Management of West Michigan reserves the right to replace or not replace all products. No refunds.

Shipping and Delivery: Free shipping is included for all products that do not require cold shipping. Cost of cold shipping of nutrient injections are the responsibility of the customer/purchaser. Cold shipping is required for the following nutrient injections: Glutathione, Vitamin C, Super Recovery Amino Blend, and Vitamin C. A flat rate of $20 will be applied to cover cold shipping when purchasing any of the above listed nutrient injections.

By voluntarily clicking consent of treatment, I release Age Management of West Michigan and its staff from all legal and medical-legal responsibility associated with products and services provided. I affirm that I have read or have had read to me the above consent to treatment and risks of treatment and understand consent of treatment. I have been recommended to fully read the consent form and have been given all the time I need to read and understand this form.