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Sermorelin NAD+ Glutathione BPC-157

Have you ever taken BPC-157, NAD+, glutathione, or sermorelin and experienced a reaction?

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Do you have any history of kidney or liver disease?

Yes No

Are you currently diagnosed with any autoimmune diseases or chronic infections?

Yes No

Do you have any history of neurological issues, such as strokes or seizures?

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Are you currently pregnant, breastfeeding, or trying to conceive?

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Are you currently taking insulin, diabetes medications, high-dose steroids, or thyroid medications?

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Are you currently taking Metformin?

Yes No

Are you currently taking antidepressants or anti-anxiety medications?

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Are you taking niacin, the dietary supplement?

Yes No

Are you currently undergoing chemotherapy, or have you completed treatment within the last six months?

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Are you taking blood thinners? If so, which ones?

Consent for Treatment I consent to receive medical evaluation and treatment from Hamilton Health & Wellness, including telehealth services. I understand that treatment may include, but is not limited to, diagnosis, prescription, and ongoing management of my condition. I authorize communication via text message and email to facilitate my care, acknowledging that while reasonable safeguards are in place, these methods may carry inherent privacy risks. I confirm that I have reviewed and accepted the Terms of Use, Privacy Policy, HIPAA Notice of Privacy Practices, and Patient Consent, all accessible at https://hamiltontelehealth.com/terms-of-service/.

I acknowledge that: Telehealth services may involve electronic transmission of medical records, images, and personal health information. My provider may determine that in-person evaluation is necessary based on clinical judgment. I will follow up with my in-person provider routinely and discuss any new treatments with them prior to starting them.

By signing below, I confirm that: I have read and understood the information above. I voluntarily consent to the treatment and services provided. I understand that my electronic signature is legally binding and equivalent to a handwritten signature. I affirm that all personal and medical information I have provided is accurate and complete to the best of my knowledge.

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