Comprehensive Peptide, Metabolic & Compounded Therapy Intake + Consent

Kindly submit the intake form prior to your consultation

Optimize by JaeNix | JaeNix, PLLC
5301 Alpha Road, Suite 34, Room 21 Dallas, TX 75240
📞 214-890-6180 ✉️ [email protected]
Treating Provider: Jessica Boggs, APRN, FNP‑C, ENP‑C
Medical Director: Simal Patel, MD

PATIENT IDENTIFICATION

First Name *

First Name

Last Name *

Last Name

Phone Number *

Please enter a valid phone number.

Date of birth *

Date

State where you are physically located today *

MEDICAL SCREENING

(Check all that apply)

PROGRAM PURPOSE

You are enrolling in a physician-directed wellness and medical optimization program that may include:

• Peptide therapy

• GLP-1 metabolic therapy (tirzepatide, semaglutide, etc.)

• Longevity & mitochondrial support

• Hormone & sexual health therapies

• Cognitive, mood, and sleep peptides

• Aesthetic & tissue-healing peptides

These therapies are used to support:

• Weight loss & metabolic health

• Injury, surgical, or tissue recovery

• Skin, hair, and aesthetic remodeling

• Energy, cognition, and mood

• Hormonal and sexual wellness

• Longevity and healthy aging

MEDICATION CATEGORIES

Please select options you are interested in discussing from the following categories:

Metabolic & Weight Loss

Healing & Regeneration

Growth Hormone Support

Cognitive / Mood / Sleep

Semax

Selank

DSIP

Sexual & Hormonal Health

PT-141 (injectable or nasal)

Tadalafil

Oxytocin

Enclomiphene

Energy & Specialty

NAD+

Methylene Blue

Low-Dose Naltrexone

COMPOUNDING PHARMACY DISCLOSURE

I understand:

• These medications are prepared by licensed 503A or 503B U.S. compounding pharmacies

• Compounded medications are not FDA-approved finished products

• They are prescribed when commercial products are unavailable or not clinically appropriate

• The pharmacy — not Optimize by JaeNix — is responsible for sterility, potency, formulation, and manufacturing

• JaeNix PLLC does not manufacture medications

I acknowledge that:

• Many peptides and metabolic agents (including tirzepatide in compounded form) are prescribed off-label

• Off-label prescribing is legal, ethical, and common

• The FDA regulates drugs, not medical practice

• My provider uses clinical judgment, safety data, and my medical history to guide prescribing

TELEHEALTH CONSENT

I agree that:

• My visit may occur via live, HIPAA-compliant audio/video

• I must be physically located in a state where my provider is licensed

• Some therapies may legally require in-person visits

• My care may be delayed, modified, or declined to maintain state or federal compliance

RISKS & SIDE EFFECTS

Possible side effects may include:

• Injection-site reactions

• Nausea, vomiting, constipation, or bloating

• Fatigue, dizziness, or headache

• Sleep or mood changes

• Blood sugar changes

• Hormonal or metabolic shifts

• Rare allergic reactions

I understand that some peptides have limited long-term human data and unknown risks may exist.

CONTRAINDICATIONS

These therapies are not appropriate for:

• Pregnancy or breastfeeding

• Active cancer or hormone-sensitive tumors

• Certain endocrine, liver, or kidney disorders

• Uncontrolled medical illness

My provider will determine medical eligibility.

FINANCIAL RESPONSIBILITY

I acknowledge:

• Compounded medications are not covered by insurance

• I am responsible for medication, shipping, and pharmacy charges

• No refunds once medications are ordered

PATIENT RESPONSIBILITIES

I agree to:

• Provide complete medical information

• Follow dosing instructions

• Not share or misuse medications

• Attend follow-ups if required

• Report side effects

NO GUARANTEE

I understand:

• Results are not guaranteed

• Benefits may be partial, temporary, or absent

• Dosing may change or therapy may be discontinued

By signing below, I confirm: *

I understand these therapies are compounded and often off-label

I consent to telehealth when applicable

I authorize prescribing through licensed compounding pharmacies

I understand tirzepatide and peptide therapies are elective

I assume the risks associated with treatment

Please list any medications you take:

Please list any allergies you have: