Superpower Health

Informed Consent for VIP Nasal Spray

Last Updated and Effective:
1.12.2025

INTRODUCTION

THIS INFORMED CONSENT (THE"CONSENT") FOR VIP NASAL SPRAY SETS FORTH THE TERMS AND POLICIES FOR THE CLINICAL SERVICES PROVIDED BY SUPERPOWER MEDICAL GROUP OF CA PC, A CALIFORNIA PROFESSIONAL MEDICAL CORPORATION, AND OTHER THIRD-PARTY MEDICAL GROUPS (COLLECTIVELY, THE "MEDICAL GROUPS") THROUGH THE ONLINE TECHNOLOGY PLATFORM ("PLATFORM" OR "SUPERPOWER PLATFORM"), WHICH IS OWNED AND OPERATED BY SUPERPOWER HEALTH, INC. ("SUPERPOWER").

The purpose of this consent is to provide you with information about the risks, benefits, and safety considerations associated with VIP Nasal Spray in order for you to make an informed decision as to whether or not to proceed with treatment, as well as to obtain your agreement to adhere to the treatment protocol as prescribed by your Medical Group healthcare provider ("Healthcare Provider"). Please read this form carefully and ask any questions you have before signing.

GENERAL INFORMATION

VIP (Vasoactive Intestinal Peptide) is a naturally occurring neuropeptide with anti-inflammatory, immune-modulating, and neuroprotective effects. It is commonly used in the treatment of ChronicInflammatory Response Syndrome (CIRS), mold illness, neuroinflammatory disorders, and other chronic conditions that involve dysregulation of the immune and neurological systems.

Aviptadil, a synthetic form of vasoactive intestinal peptide (VIP), has been granted U.S. Food and DrugAdministration (FDA) Fast Track Designation for treating critical COVID-19 with respiratory failure. However, you should be aware that compounded VIP nasal spray has not been evaluated for safety, quality and efficacy by the FDA and has not been approved by the FDA for the treatment of any disease or medical condition.

How does VIP work (mechanism of action)?

  • Immune Modulation: VIP decreases pro-inflammatory cytokines and increases anti-inflammatory cytokines, helping to restore immune system balance.
  • Improved Cellular Signaling: It enhances cellular communication and supports the repair of damaged tissues, particularly in the nervous and gastrointestinal systems.
  • Tight Junction Restoration: VIP helps restore the integrity of the gut and blood-brain barrier, reducing systemic inflammation.
  • Neuroprotection: It supports the repair and regeneration of neuronal pathways and promotes brain health.
  • Cardiovascular Support: VIP improves microcirculation by relaxing vascular smooth muscle and increasing blood flow.

As with all therapies, there are potential benefits and risks.

Potential Benefits of VIP Nasal Spray:

  • Reduces systemic inflammation.
  • Improves cognitive function, including brain fog and memory.
  • Enhances energy levels and reduces fatigue.
  • Supports gut health and reduces symptoms of leaky gut.
  • Promotes resilience to environmental triggers, such as mold or allergens.

Potential Side Effects of VIP Nasal Spray:

  • Common: Nasal irritation, mild headaches, and initial fatigue.
  • Less Common: Temporary detox-like symptoms, including mild nausea or worsening of symptoms during the initial adjustment period.
  • Rare: Allergic reactions, shortness of breath, or dizziness.

These are not all the possible side effects and risks of using VIP Nasal Spray.

TREATMENT PROTOCOL

Your Healthcare Provider will determine the appropriate dosage of VIP Nasal Spray based on your medical history, lab results, and clinical symptoms.

Standard Dosing Schedule:
  1. Weeks 1-2: Start with 50 mcg twice daily.
  2. Weeks 3-4: Increase to 100 mcg twice daily, as tolerated.
  3. Month 2 and beyond: Maintain 200 mcg twice daily, adjusting as necessary based on clinical response and side effects.
Monitoring Requirements:
  • Pre-treatment Testing: Baseline lab testing, including inflammatory markers (e.g., TGF-beta1, C4a, MMP-9), will be required prior to starting treatment.
  • Ongoing Monitoring: Repeat labs at 3 months and then every 6-12 months to track progress and ensure safety.
Adherence:

It is critical to adhere to the prescribed dosing schedule and to communicate any new or worsening symptoms to your Healthcare Provider promptly

ALTERNATIVES TO VIP NASAL SPRAY

There are alternative treatments for chronic inflammation and immune dysregulation, including:

  • Dietary modifications and nutritional supplements.
  • Detoxification therapies (e.g., binders like cholestyramine or activated charcoal).
  • Stress management and lifestyle changes.

These alternatives may not provide the same benefits as VIP Nasal Spray and should be discussed with your Healthcare Provider.

CONTRAINDICATIONS

You should not use VIP Nasal Spray if:

  • You have an allergy to any of its components.
  • You have untreated infections, as VIP may suppress certain immune responses.
  • You are pregnant, breastfeeding, or planning to become pregnant without consulting your Healthcare Provider.

ADDITIONAL SAFETY INFORMATION

  • Inform your Healthcare Provider of all medications, supplements, and herbal products you are taking to avoid potential interactions.
  • Avoid alcohol and recreational drugs during treatment, as they may interfere with the effectiveness of VIP.
  • If you experience severe side effects, such as difficulty breathing or persistent dizziness, discontinue use and contact your Healthcare Provider immediately.

USE OF TELEHEALTH

Your Clinical Services will be provided via telehealth. Telehealth involves the use of electronic communication for diagnosis, treatment, and follow-up care. By agreeing to this Consent, you acknowledge the following:

  • Telehealth provides improved access to care but may limit the ability to perform a full physical examination.
  • There are potential risks, including delays due to technical issues or security breaches.
  • You must be physically located in the state where your Healthcare Provider is licensed during telehealth visits.

INFORMED CONSENT & ADHERENCE TO TREATMENT PLAN

By signing this informed consent, you acknowledge that you:

  1. Have read and understood the information provided about VIP Nasal Spray, including its risks, benefits, and safety considerations. You understand that VIP is not approved by the FDA to treat any disease or medical condition.
  2. Agree to adhere to the treatment protocol as prescribed by your Healthcare Provider and report any severe side effects or concerns promptly.
  3. Understand that there are no guarantees or assurances regarding treatment outcomes.

Certify that you have disclosed all relevant health information, including allergies, medications, and medical history to your Superpower Healthcare Providers.

CERTIFICATION OF CONSENT

By clicking "I AGREE" or signing below, you certify that:

  • You have read and understood this entire Informed Consent.
  • You have had the opportunity to ask questions, and all your questions have been answered to your satisfaction.
  • You freely and voluntarily accept all risks associated with VIP Nasal Spray and consent to proceed with treatment.

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MEMBER NAME:___________________________

SIGNATURE:______________________________

DATE:____________________________________

 

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