H&P CERTIFICATION — SERMORELIN INJECTIONS

KosherMedications.com
Health & Physical (H&P) Self-Assessment Declaration

By completing my purchase of Sermorelin Injections through KosherMedications.com, I certify under penalty of perjury that the following statements are true and correct to the best of my knowledge and belief. I understand that a licensed healthcare provider will rely upon this information when determining whether a prescription or compounded preparation is clinically appropriate.

General Information

I affirm that I:

• am 18 years or older, completing this assessment for myself, voluntarily, and providing accurate identifying information including my full name, address, and contact details.

• will use this service and any prescribed medication solely for myself and will not share or distribute it to others.

• understand that Sermorelin may be dispensed only if medically appropriate, based on my self-reported information and provider review.

• acknowledge that a licensed healthcare provider may contact me for clarification or additional information before approval.

• have reviewed and accepted KosherMedications.com’s Terms of Service and Consent to Telehealth, which govern this interaction and any related care.

Consent to Telehealth

I understand and acknowledge that:

• This service uses an asynchronous telehealth model, allowing me to provide medical information online for review by a licensed provider.

• A valid provider-patient relationship is created for this encounter and may include follow-up communication if needed.

• Telehealth is a supplemental mode of care and does not replace in-person evaluation or ongoing monitoring by my primary provider.

• Because of the nature of telemedicine, the reviewing provider cannot continuously monitor my condition, lab results, or side effects. I accept these limitations and associated risks.

• All personal and medical information will be transmitted and stored securely, in compliance with HIPAA and applicable privacy laws.

• In the event of a medical emergency, I will call 911 or seek immediate in-person emergency care and will not rely on telehealth communication for urgent or life-threatening issues.

Clinical Information Related to Sermorelin Injections

I confirm that I:

• understand that Sermorelin is a growth hormone–releasing hormone (GHRH) analog used to support endogenous growth hormone production, recovery, sleep quality, and lean body composition — but is not FDA-approved for anti-aging or performance enhancement.

• understand that Sermorelin requires adequate pituitary function and may not be effective in individuals with certain endocrine or pituitary disorders.

• have not experienced hypersensitivity or allergic reactions to Sermorelin or its components.

• do not have active or previous malignancy, including:

  • cancers dependent on growth hormone or IGF-1

  • active tumors or suspicious masses

  • untreated pituitary adenomas

• do not have severe or uncontrolled medical conditions that may increase the risk of therapy, including:

  • uncontrolled hypertension

  • heart failure or significant cardiac disease

  • severe liver or kidney impairment

  • uncontrolled diabetes or diabetic retinopathy

• am aware that Sermorelin may cause side effects including:

  • facial flushing

  • headache

  • nausea

  • dizziness

  • injection site redness, swelling, or discomfort

  • tingling or warmth sensations

• understand that Sermorelin may increase levels of IGF-1, and excessive IGF-1 may carry health risks; monitoring may be required.

• understand that Sermorelin should be administered exactly as directed, typically at bedtime to support the body’s natural GH rhythm.

• will discontinue use and seek medical attention if I experience:

  • chest pain or breathing difficulty

  • persistent headaches

  • swelling in joints or extremities

  • signs of allergic reaction

• am not pregnant or breastfeeding, and will notify a provider if that changes.

• will inform my reviewing provider of all medications, supplements, and hormones I am taking, including testosterone, thyroid medication, steroids, or peptides.

• understand that Sermorelin is often compounded and that compounded medications are not FDA-approved, though they are prepared in licensed compounding facilities according to U.S. standards.

Health Status & Representations

I attest that I:

• am in generally good health, apart from the condition or purpose for which I am seeking Sermorelin.

• have truthfully disclosed all relevant medical history, medications, hormone therapies, and allergies.

• understand that my information may be reviewed by a licensed provider, who may request additional clarification before issuing a prescription.

• confirm that this certification represents all relevant health information I would disclose during an in-person medical visit.

General Information About Prescription or Compounded Medications

I understand that:

• This certification does not include every possible risk, interaction, or side effect related to Sermorelin Injections.

• Sermorelin may be compounded, and compounded medications are not reviewed or approved by the FDA but are prepared under U.S. compounding regulations.

• Additional information about medications and drug interactions can be found at:

  • www.fda.gov

  • www.drugs.com/drug_interactions.html

• I will review all instructions, medication guides, and compounding materials provided with the prescription and consult with my provider if I have additional questions.

Pharmacy & Fulfillment Information

I acknowledge that:

• KosherMedications.com partners with licensed pharmacies and compounding facilities to dispense medications in accordance with applicable laws.

• Reviewing providers act independently and are not employees of the pharmacy.

• I consent to receive education materials, refill notices, and treatment updates electronically.

• I am responsible for reviewing this certification and contacting support@koshermedications.com with any questions before starting treatment.

Emergency Disclaimer

I understand that KosherMedications.com and its affiliated providers do not provide emergency medical services.
In the event of an emergency or severe reaction, I will call 911 or seek immediate in-person care at the nearest emergency department.

By completing my purchase, I affirm that all statements above are true, accurate, and complete to the best of my knowledge.