1. B12:
   Vitamin B-12 helps maintain good health and has been shown to be beneficial in helping to: Reduce stress, fatigue, improve memory and cardiovascular health, and maintain a a good body weight. It can also assist the body in converting proteins, fats and carbohydrates into energy and is necessary for healthy skin and eyes.
2. NAD+ (Nicotinamide Adenine Dinucleotide):
   NAD+ is a coenzyme present in all living cells, crucial for cellular energy production, metabolism, and the regulation of several physiological processes. NAD+ infusion or supplementation may be used to help with energy levels, cognitive function, and overall cell repair.
3. Glutathione:
   Glutathione is a powerful antioxidant that helps reduce oxidative stress, support detoxification, and promote overall immune function. It is commonly administered to support liver function, improve skin health, and enhance immune resilience.
4. MIC (Methionine, Inositol, Choline):
   This combination of nutrients is often used to promote fat metabolism, support liver function, and help with weight management. These ingredients work together to enhance energy, reduce fat storage, and support overall metabolic health.
5. Immune Boost (Zinc & Ascorbic Acid):
   Zinc and Ascorbic Acid (Vitamin C) are vital nutrients that support the immune system, reduce inflammation, and help the body fight off infections. They also have antioxidant properties that help protect cells from damage caused by free radicals.
6. Sermorelin:
   Sermorelin is a peptide that stimulates the pituitary gland to release growth hormone. It is used to promote healthy aging, improve muscle mass, and enhance overall vitality and energy.

General Contraindications All Injections

I will inform my provider and confirm all of the following:

• I have no known allergies to any components of the injection or preservatives
• I am not currently pregnant or breastfeeding
• I am do not have active cancer and I am not undergoing chemotherapy or radiation
• I do not have an active infection at or near the injection site

B12

Risks / Side effects

I understand that although rare Vitamin B12 injections can result in serious side effects. Although this is a relatively rare occurrence, anyone taking vitamin B12 injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of B12 injections, and such side effects should be reported to a physician to be evaluated for seriousness. Uncommon and dangerous side effects include:

• rapid heartbeat
• chest pain
• flushed face
• muscle cramps and weakness
• difficulty breathing and swallowing
• dizziness
• confusion
• rapid weight gain
• tight feelings in the chest
• hives, skin rashes
• shortness of breath when there is no physical exertion and unusual wheezing and coughing.

Contraindications

I confirm that:

• I do not have an allergy to cobalt or Vitamin B12.
• I do not have Leber’s disease.
• I do not have kidney or liver disease.
• I do not have polycythemia vera, iron deficiency, or folic acid deficiency.
• I am not receiving any treatment or taking any medication that affects bone marrow function.
• I am not currently taking a monoamine oxidase inhibitor (MAOI) or a selective serotonin reuptake inhibitor (SSRI).
• I understand that Vitamin B12 injections may potentially worsen acne if I am acne-prone

NAD+

Risks / Side effects:

I understand that although rare, NAD+ injections can result in serious side effects. Although this is a relatively uncommon occurrence, anyone receiving NAD+ injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of NAD+ therapy, and such reactions should be promptly reported to a physician for evaluation. Uncommon and potentially dangerous side effects include:

• Headaches
• Nausea
• Fatigue
• Dizziness
• Skin irritation at the injection site (if applicable)

Contraindications

I confirm that:

• I understand that NAD+ can improve cellular activity and cancer cells can also respond
• I do not have cancer or a history of cancer
• I do not have active liver disease
• I do not have low blood pressure or hypotension
• I do not have cardiac arrhythmias
• I am not being treated for anxiety or panic disorders (without clearance)
• I do not have a history of uncontrolled high blood pressure
• I do not have a thyroid condition
• I am not on a MAO inhibitor or SSRI

Because NAD can improve cellular activity, cancer cells can also respond. Patients with history of cancer or active cancer should not receive NAD injections. For that reason, it’s strongly encouraged to do routine cancer screenings and an annual physical exam with primary care provider.

Glutathione

Risks / Side effects:

I understand that although rare, Glutathione injections can result in serious side effects. Although this is a relatively uncommon occurrence, anyone receiving Glutathione injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of Glutathione therapy, and such reactions should be promptly reported to a physician for evaluation. Uncommon and potentially dangerous side effects include:

• Rare allergic reactions (rash, swelling, or itching)
• Abdominal discomfort
• Shortness of breath (very rare)

Contraindications

I confirm that:

• I do not have asthma
• I am not sensitive to sulfites
• I am not sensitive to sulfa
• I am not undergoing chemotherapy or radiation

MIC

Risks / Side effects:

I understand that although rare, MIC injections can result in serious side effects. Although this is a relatively uncommon occurrence, anyone receiving MIC injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of MIC therapy, and such reactions should be promptly reported to a physician for evaluation. Uncommon and potentially dangerous side effects include:

• Mild gastrointestinal upset
• Headaches
• Mild skin irritation or rash

Contraindications

I confirm that:

• I do not have advanced liver disease
• I do not have kidney dysfunction
• I do not have a diagnosis of bipolar disorder
• I do not have diabetes
• I am not on a blood thinner
• I am not on a MAO inhibitor or SSRI

Immune Boost

Risks / Side effects:

I understand that although rare, Immune Boost injections (containing Zinc and Ascorbic Acid) can result in serious side effects. Although this is a relatively uncommon occurrence, anyone receiving Immune Boost injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of Immune Boost therapy, and such reactions should be promptly reported to a physician for evaluation. Uncommon and potentially dangerous side effects include:

• Gastrointestinal distress (nausea, bloating, or diarrhea)
• Rare allergic reactions (rash, swelling, or difficulty breathing)
• Zinc overdose (leading to nausea, vomiting, and impaired immune function) if taken in excess
• Ascorbic acid (Vitamin C) may cause mild stomach irritation in some individuals, especially at higher doses.

Contraindications

• I do not have a history of kidney stones
• I do not have hemochromatosis
• I do not have Wilson’s disease
• I do not have a history of seizures
• I do not have a history of uncontrolled high blood pressure

Sermorelin

Risks / Side effects:

I understand that although rare, Sermorelin injections can result in serious side effects. Although this is a relatively uncommon occurrence, anyone receiving Sermorelin injections should be aware of the possibility. Uncommon side effects are much more serious than the common side effects of Sermorelin therapy, and such reactions should be promptly reported to a physician for evaluation. Uncommon and potentially dangerous side effects include:

• Allergic reactions including rash, itching, swelling, or anaphylaxis
• Injection site pain, redness, or swelling
• Headache or dizziness
• Flushing or warmth in the face or neck
• Temporary increase in cortisol or blood sugar levels
• Joint pain or muscle stiffness

Contraindications

I confirm that:

• I understand that Sermorelin can cause worsening of existing tumors or cancer growth
• I do not have cancer or a history of cancer
• I do not have uncontrolled diabetes
• I do not have a history of pituitary gland tumors or disorders
• I do not have severe cardiovascular disease
• I am not currently taking Glucocorticoids, Dopamine agonists, Dopamine antagonists, Somatostatin analogs, Estrogen therapy, Insulin and other diabetes medications

Off-Label Use Notice

Certain treatments provided during your session may involve the use of products or procedures in areas that are considered “off-label.” This means that while the treatment may not be specifically approved by regulatory bodies for the exact area being treated, it has been used in this manner based on clinical experience and evidence supporting its safety and efficacy.

Understanding Off-Label Use:

• Definition: Off-label use refers to the application of a treatment or product in a manner not specifically approved by regulatory agencies, such as the FDA. This can include using products in areas or for conditions not explicitly listed in the product’s official guidelines.
• Risks and Benefits: While off-label use can be effective and is often supported by clinical evidence and professional experience, it may carry risks or uncertainties not fully detailed in standard usage guidelines. We will provide you with information on the potential benefits and risks of the treatment and address any questions you may have.
• Informed Consent: By signing this consent form, you acknowledge that you have been informed about the off-label nature of certain treatments and agree to proceed with the understanding that these uses are based on professional judgment and experience.

If you have any concerns or questions about the treatments or their off-label use, please do not hesitate to discuss them with us before proceeding.

The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been offered a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.

I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office.

I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

I agree, if I should have any questions or concerns regarding my treatment / results I will notify this office at immediately so that timely follow-up and intervention can be provided.