Working version for review — September 17, 2026. This is the supplied form used for the website walkthrough. Final wording is pending review.
CORE MEDICAL GROUP
Canine Peptide & Testosterone Therapy — Informed Consent, Assumption of Risk, and Waiver of Liability
This Informed Consent, Assumption of Risk, and Waiver of Liability ("Agreement") is entered into between Core Medical Group, its affiliated veterinarians, staff, and telehealth partners (collectively, "Provider") and the undersigned dog owner ("Owner") in connection with the elective peptide therapy and/or testosterone (hormone) therapy program described below ("Protocol") for the dog identified below ("Patient").
1. Dog and Owner Information
Owner Name: ____________________________________________________
Dog's Name: __________________________ Breed: __________________ Age: _______ Weight: _______ lbs
Primary Veterinarian / Clinic (if not Provider): ______________________________________________
2. Description of Protocol
Owner has elected to pursue one or more of the following peptide and/or hormone therapy packages, or an à la carte combination of compounds, for Patient (check/circle all that apply):
Pre/Post Surgery & Joint Support Package (BPC-157 / TB-500)
Enhanced Pre/Post Recovery Package (BPC-157 / TB-500 / GHK)
Cognitive Support Package (NAD+ / MOTS-c)
Weight Management Package (MOTS-c / AOD-9604)
Preventative Wellness Package (NAD+ / BPC-157 / TB-500)
Performance Optimization Package (CJC-1295 / Ipamorelin / BPC-157 / GHK / TB-500)
Testosterone (hormone) therapy
À la carte add-on(s): ______________________________________________
Owner understands that most dogs begin showing noticeable improvement approximately 40 to 60 days after beginning therapy, and that individual response time varies based on the Patient's age, condition being treated, overall health, and adherence to the prescribed protocol. Provider makes no guarantee of any specific outcome, timeline, or result.
3. Human-Grade Materials — Not for Human Use
Owner understands and acknowledges that the peptides, testosterone, and other compounds used under this Protocol are sourced and manufactured to human-grade quality and purity standards, but are compounded, dosed, and labeled exclusively for veterinary (canine) administration. These products are NOT approved, packaged, or intended for human consumption, injection, or any other human use. Safe use in humans would require different formulation, sterile preparation, dosing calibration, and medical supervision that are not provided under this Protocol, and the DEA classifies testosterone as a Schedule III controlled substance subject to separate legal restrictions on human possession and use.
Owner agrees that these materials will be administered only to Patient, will be stored securely and out of reach of children and other household members, and will never be ingested, injected, or otherwise used by any person under any circumstances. If a person is accidentally exposed to or ingests any product covered by this Agreement, Owner will immediately contact Poison Control and/or seek emergency medical attention and will notify Provider as soon as reasonably possible.
Owner Initials: ______ (Owner acknowledges the human-grade / not-for-human-use disclosure above)
4. Pre-Treatment Requirements
Before beginning this Protocol, Owner confirms and acknowledges the following:
Current blood work for Patient has been completed.
Patient's white blood cell counts are within normal limits and are not elevated.
A licensed veterinarian has evaluated Patient and determined that Patient is an appropriate candidate for this therapy.
Owner Initials: ______ (Owner acknowledges the pre-treatment requirements above)
5. Ongoing Monitoring & Annual Labs
Owner acknowledges that this Protocol requires ongoing monitoring for Patient's safety, and that it is Owner's sole responsibility — not Provider's — to schedule and obtain the following, at Owner's own expense, unless otherwise arranged in writing with Provider:
Annual bloodwork/lab panels for Patient for the duration of the Protocol (or more frequently if recommended by Patient's veterinarian).
Periodic testosterone-specific lab testing (e.g., serum testosterone levels) at intervals recommended by Patient's veterinarian, if Patient is receiving testosterone (hormone) therapy.
Regular visual and physical prostate examinations performed by a licensed veterinarian, if Patient is receiving testosterone (hormone) therapy, to monitor for prostate enlargement or other changes.
Owner understands that skipping or delaying this ongoing monitoring may increase health risks to Patient, and that Provider may pause, modify, or discontinue the Protocol if Owner does not provide documentation of required labs and exams upon request.
Owner Initials: ______ (Owner acknowledges responsibility for annual labs, testosterone labs, and prostate exams above)
6. Assumption of Risk
Owner understands that peptide therapy and testosterone (hormone) therapy in dogs is an evolving area of veterinary medicine, that not all compounds used under this Protocol are FDA-approved for veterinary use, and that individual results and side effects cannot be guaranteed or fully predicted. Potential risks may include, without limitation: injection-site irritation or infection; gastrointestinal upset; allergic or hypersensitivity reactions; behavioral or hormonal changes (including increased aggression, changes in appetite, or changes in coat or skin); effects on the prostate or other organs associated with hormone therapy; interactions with other medications or health conditions; and other unknown or unanticipated effects. Owner voluntarily assumes all such known and unknown risks associated with the Protocol.
7. Owner Responsibilities
Administer all products only as directed by Provider and/or Patient's veterinarian, and never exceed the prescribed dosage.
Store all products securely, out of reach of children, other pets, and household members.
Monitor Patient for any adverse reaction and discontinue use and contact Provider or Patient's veterinarian immediately if one occurs.
Provide accurate and current health information about Patient, including any medications, supplements, or pre-existing conditions.
Seek immediate veterinary or emergency care if Patient shows signs of a serious adverse reaction.
8. Release and Waiver of Liability
In consideration of Provider making this Protocol available, Owner, on behalf of themselves and their heirs, executors, and assigns, releases and forever discharges Provider, its owners, veterinarians, employees, contractors, and telehealth partners from any and all claims, demands, damages, costs, or causes of action arising out of or related to Patient's use of the Protocol, including but not limited to any adverse reaction, injury, illness, or death, except to the extent caused by Provider's gross negligence or willful misconduct. This release does not waive any rights or protections that cannot be waived under applicable law.
9. Voluntary and Informed Consent
Owner confirms that they have read this Agreement in full, have had the opportunity to ask questions and discuss the Protocol and its risks with a veterinarian, and voluntarily consent to Patient's participation in the Protocol on behalf of Patient.
10. Governing Law
This Agreement shall be governed by the laws of the State of ____________________, without regard to its conflict-of-laws principles.
11. Signatures
By signing below, Owner acknowledges they have read, understood, and agree to all terms of this Agreement.
________________________________
Owner Signature
________________________________
Date
________________________________
Owner Name (printed)
________________________________
Dog's Name
________________________________
Provider / Clinic Representative
________________________________
Date
This document is a template for internal use and does not constitute legal advice. Because it involves a controlled substance (testosterone) and veterinary telehealth, Core Medical Group should have this Agreement reviewed by an attorney licensed in each state where it will be used before it is put into use.