Peptide Therapy (NON GLP1) Intake

Peptides are short chains of amino acids that act as signaling molecules in the body — supporting healing, recovery, immune function, hormone

optimization, gut health, cognitive performance, and more.

Unlike GLP-1s used specifically for metabolic support,

the peptides offered through this program are prescribed

for a broad range of wellness and optimization goals.

All peptide therapy at Kōena is provider-guided and requires a clinical evaluation to determine candidacy.

Please complete this form as thoroughly as possible —

your answers help us understand your health history

and goals so we can build the right protocol for you.

All information is confidential.

POTENTIAL BENEFITS OF PEPTIDE THERAPY:

BPC-157 — Accelerates tissue repair, supports gut lining integrity, reduces inflammation, aids joint and tendon healing.

TB-500 (Thymosin Beta-4) — Promotes tissue regeneration, reduces inflammation, supports recovery from injury. Often used alongside BPC-157 for enhanced results.

CJC-1295 — Stimulates natural growth hormone production supporting muscle growth, fat reduction, improved sleep, and skin elasticity.

Ipamorelin — Promotes growth hormone release, improves body composition, enhances recovery, sleep quality, and overall vitality.

Sermorelin — Naturally stimulates growth hormone secretion supporting anti-aging, energy, metabolism, and muscle tone.

Tesamorelin — Supports reduction of visceral fat, improves body composition, and supports metabolic health.

PT-141 (Bremelanotide) — Supports libido and sexual function in both men and women through melanocortin receptor activation.

MOTS-c — Supports metabolic health, insulin sensitivity, cellular energy, and healthy aging.

GHK-Cu — Stimulates collagen production, supports skin health, wound healing, anti-aging, and tissue repair.

AOD-9604 — Supports fat metabolism and body composition without affecting blood sugar or growth hormone levels.

POTENTIAL RISKS:

The following risks apply to peptide therapy generally and may vary by specific peptide and individual:

- Injection site reactions — redness, swelling, bruising, or discomfort at injection site

- Nausea, fatigue, or headache — typically mild and transient

- Water retention or temporary bloating (growth hormone peptides)

- Flushing or warmth (PT-141, CJC/Ipamorelin)

- Increased hunger (growth hormone peptides)

- Temporary changes in blood sugar levels

- Unknown long-term risks — peptide therapy is an evolving field and long-term human safety data is limited for some compounds

- Individual results are not guaranteed and vary based on health history, lifestyle, dosing, and compliance

I have read and understand the benefits and risks of the peptide therapy outlined above. All of my questions have been answered fully and to my

satisfaction.

I confirm the following:

- I do not have an active cancer diagnosis

- I am not currently pregnant or breastfeeding

- I do not have an uncontrolled autoimmune disease

- I do not have severe organ disease (kidney,

liver, or heart)

- I do not have a known allergy to peptides

or amino acids

- I am not currently experiencing an active

infection or illness

I understand that peptides are generally well

tolerated and considered safe when prescribed

and monitored by a licensed provider. I understand

that these are compounded medications and that

some peptides are prescribed off-label. I

acknowledge that no guarantee of desired results

has been made.I understand that my peptide therapy at Kōena

Integrative Medicine is prescribed by and under

the supervision of Medical Director Courtney

Williams, NP.

I choose to proceed with peptide therapy of my

own free will and accept full understanding of

both the benefits and risks involved.

By typing my full name below I am providing

my electronic signature confirming that I have

read, understood, and agree to all of the above.