Oxytocin Nasal Spray
At this time Oxytocin nasal spray is only prescribed to patients residing in states where Dr. Mahjoubi is currently licensed: Arizona, California, Connecticut, Florida, Illinois, Massachusetts, New Jersey, New Mexico, New York, Texas, Utah, Virginia, and Wisconsin.
*
I understand and live in one of these states
I dont live in one of these states
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list all medications currently being taken- dosage not needed. If you do not take any medication write "none."
*
INFORMED CONSENT FOR COMPOUNDED OXYTOCIN NASAL SPRAY1. PURPOSE OF TREATMENTI, the undersigned, am voluntarily requesting treatment with compounded oxytocin nasal spray, prescribed by Dr. David Mahjoubi, MD, and prepared by a licensed compounding pharmacy. I understand that oxytocin is a naturally occurring hormone, and that the FDA-approved forms of oxytocin (such as injectable Pitocin) are approved only for use in labor and postpartum care. The intranasal compounded formulation prescribed to me is not FDA-approved as a finished product, and its use for mood, anxiety, sleep, social bonding, pain, or any other indication is considered off-label.2. POTENTIAL BENEFITSI understand that the following are potential benefits that some patients have reported and that have been suggested by limited research, but that none of these benefits are guaranteed and that responses vary significantly from person to person:- Subjective improvement in mood and feelings of relaxation- Reduced perceived anxiety in some social contexts- Subjective sense of enhanced emotional connection and trust- Possible improvement in sleep quality- Possible reduction in the perception of painI acknowledge that the published research on intranasal oxytocin for these uses is limited, mixed, and largely conducted in research settings rather than clinical practice. I understand that the medication may have no effect, a small effect, or in rare cases a paradoxical or unwanted effect.3. POTENTIAL SIDE EFFECTS AND RISKSI understand that potential side effects of compounded oxytocin nasal spray include, but are not limited to:- Mild nasal irritation, burning, or discomfort at the application site- Headache- Nausea- Drowsiness or fatigue- Changes in mood, including emotional sensitivity, tearfulness, or, in some patients, increased rather than decreased anxiety- Changes in heart rate or blood pressure (including drops in blood pressure or, less commonly, increases)- Flushing or warmthI also understand that less common but more serious risks may include:- Water retention, low blood sodium (hyponatremia), and, in rare and severe cases, seizures or confusion related to fluid imbalance — particularly with high doses or excessive water intake- Cardiovascular effects including arrhythmia, palpitations, or fainting in patients with underlying cardiac conditions- Allergic reactions to the medication, preservatives, or excipients in the compounded formulation, ranging from mild rash to anaphylaxis- Paradoxical worsening of mood symptoms, anxiety, or emotional distress, especially in patients with certain psychiatric conditions- Unpredictable interactions with other medications, supplements, or substances I am takingI understand that the safety and side-effect profile of long-term intranasal oxytocin use is not well established.4. CONTRAINDICATIONSI understand that compounded oxytocin nasal spray is NOT appropriate, and I should not use it, if any of the following applies to me:- I am pregnant, may be pregnant, am trying to become pregnant, or am breastfeeding. Oxytocin causes uterine contractions and is the active ingredient in medications used to induce labor. Use during pregnancy can cause miscarriage, premature labor, fetal distress, or other serious harm.- I have uncontrolled cardiovascular disease, severe arrhythmia, recent heart attack, or significant hypotension or hypertension.- I have a history of severe psychiatric illness in active or unstable phase, including untreated psychosis, acute mania, or current psychiatric crisis.- I have a history of significant hyponatremia, syndrome of inappropriate antidiuretic hormone (SIADH), or severe kidney disease.- I have a known allergy to oxytocin or to any preservative or excipient in the compounded formulation.I have disclosed my complete and accurate medical history, current medications, supplements, and allergies to Dr. David Mahjoubi, MD. I understand that providing incomplete or inaccurate information may put my safety at risk and may waive certain claims arising from undisclosed conditions or medications.5. DRUG AND SUBSTANCE INTERACTIONSI understand that compounded oxytocin nasal spray may interact with other medications, supplements, and substances, including but not limited to:- Ergot-derivative medications (such as those used for migraine), which combined with oxytocin can cause severe high blood pressure- Systemic vasoconstrictors and high-dose decongestants- MAOI antidepressants, lithium, and certain other psychiatric medications- Other intranasal prescription medications- Diuretics and other medications that affect fluid and sodium balance- Alcohol and recreational substances, which may amplify drowsiness, mood effects, or unpredictable reactionsI will inform Dr. David Mahjoubi, MD of every medication, supplement, and substance I am taking before starting this medication, and I will inform the clinic of any new medications I begin while using this nasal spray.6. PREGNANCY, BREASTFEEDING, AND REPRODUCTIVE CONSIDERATIONSI understand and acknowledge separately that I must not use this medication if I am pregnant, may become pregnant during the period I would be using it, or am breastfeeding. I will discontinue use immediately and notify the clinic if I become pregnant or suspect I may be pregnant while using this medication. I understand that oxytocin's primary medical use is to induce uterine contractions, and that even though intranasal absorption is lower than injectable, the medication can still affect a developing pregnancy.7. NO GUARANTEE OF BENEFITSI acknowledge that Dr. David Mahjoubi, MD makes no guarantee, express or implied, regarding the results of using compounded oxytocin nasal spray. I understand that effects vary significantly between patients, that some patients experience no benefit, and that no particular clinical outcome is assured. I further understand that this medication is not a substitute for evidence-based treatment of any diagnosed psychiatric, medical, or pain condition, and that I should continue to receive routine medical and mental-health care from my primary providers.8. ALTERNATIVE TREATMENT OPTIONSI understand that there are evidence-based alternatives for the symptoms I am hoping to address, including but not limited to: psychotherapy, FDA-approved medications for anxiety, depression, or sleep, lifestyle interventions, and consultation with a psychiatrist, primary care physician, or other licensed clinician. I have considered these alternatives and am choosing to proceed with compounded oxytocin nasal spray with full knowledge of its potential benefits, risks, and the off-label nature of this use.9. TELEHEALTH RELATIONSHIP AND TRUTHFUL DISCLOSUREI understand that my care relationship with Dr. David Mahjoubi, MD for this medication is conducted via telehealth and is limited in scope to the prescribing of compounded oxytocin nasal spray. No physical examination is being performed. I have provided truthful and complete information on my intake form. I understand that providing false or incomplete information may waive certain claims and may result in immediate discontinuation of the prescription.10. REPORTING ADVERSE EFFECTS AND DISCONTINUATIONI will contact the clinic promptly if I experience any new or concerning symptoms while using this medication, including but not limited to: persistent headache, confusion, severe nausea, racing or irregular heartbeat, fainting, severe mood changes, swelling, difficulty breathing, or any symptom I believe may be related to the medication. I understand that I may discontinue use at any time, and I agree to notify the clinic if I do so. I understand that in the event of a medical emergency, I should call 911 or go to the nearest emergency room rather than wait for a clinic response.If I experience thoughts of suicide or self-harm at any time, I will call or text 988 (the 988 Suicide and Crisis Lifeline) or seek emergency care immediately.11. VOLUNTARY CONSENTI have read and fully understand the information provided in this consent form. I have had the opportunity to discuss compounded oxytocin nasal spray treatment with Dr. David Mahjoubi, MD, if I so chose, and have had all of my questions answered to my satisfaction. By signing this form, I voluntarily consent to receive a prescription for compounded oxytocin nasal spray and to use it as directed. I confirm that I am at least 18 years of age. I understand that I may withdraw this consent and discontinue use at any time. Important Safety InformationCompounded oxytocin nasal spray is a prescription medication formulated under physician direction by a licensed compounding pharmacy (Novel Pharmacy, Sylmar, California). Compounded preparations are not FDA-approved as finished products. Oxytocin is FDA-approved only as an injectable (Pitocin®) for use during labor and delivery; intranasal oxytocin is not FDA-approved for any indication. Any use described on this page — including for emotional connection, bonding, mood, anxiety, or libido — is considered off-label and is supported by emerging clinical research rather than FDA evaluation. Patients should weigh this with their physician before starting therapy.WARNING — Pregnancy and Breastfeeding. Oxytocin is a uterotonic hormone — its injectable form (Pitocin®) is used clinically to induce labor and contract the uterus. Although intranasal dosing is much lower, oxytocin is absorbed systemically and may stimulate uterine contractions. Compounded oxytocin nasal spray must NOT be used by anyone who is pregnant, suspects she may be pregnant, is actively trying to become pregnant, or is breastfeeding. Use during pregnancy may cause miscarriage, premature labor, or fetal harm. Use during breastfeeding may interfere with milk let-down and pass to the infant. Women of childbearing age should use reliable contraception during therapy and notify Dr. Mahjoubi immediately if they become pregnant.This product is also contraindicated in patients with: known hypersensitivity to oxytocin; a history of cardiovascular disease, uncontrolled hypertension, or recent heart attack; significant electrolyte disorders or hyponatremia (low sodium); active or prior eating-disorder behavior in which water intake is dysregulated; and any condition affecting the nasal passages that would impair absorption or worsen with topical exposure (active sinus infection, recent nasal surgery, severe deviated septum, or chronic epistaxis). Patients on vasoconstrictor medications (including some migraine medications) should not use oxytocin without specific physician approval, because the combination can cause sudden severe hypertension.Possible side effects include nasal irritation or congestion; headache; flushing; transient changes in blood pressure or heart rate; nausea; uterine cramping in women; and — with high or repeated dosing — hyponatremia (water intoxication) presenting as confusion, severe headache, seizure, or unusual fluid retention. Psychological side effects can include heightened emotional reactivity, irritability, or, paradoxically, increased anxiety in some patients. Discontinue use and contact Dr. Mahjoubi if any side effect is bothersome or persistent. Seek emergency medical care immediately for severe headache, confusion, seizure, chest pain, fainting, allergic reaction, or — in pregnant or possibly pregnant patients — any abdominal cramping, vaginal bleeding, or contractions.Because compounded oxytocin nasal spray is a prescription medication, it is dispensed only after physician evaluation and only to patients residing in states where Dr. Mahjoubi is currently licensed: Arizona, California, Connecticut, Florida, Illinois, Massachusetts, New Jersey, New Mexico, New York, Texas, Utah, Virginia, and Wisconsin. Prescriptions cannot be issued to patients in any other state. This product is intended for adult patients only and should be stored, handled, and used only by the prescribed individual.
*
☐ I plan to not drive a vehicle, operate heavy machinery, or perform other safety-sensitive tasks within 2 hours of using this nasal spray?☐ I understand that oxytocin nasal spray is a compounded medication, is not FDA-approved as a finished product, and is being prescribed off-label for mood, anxiety, sleep, social bonding, or pain.☐ I understand that oxytocin is a prescription medication with possible side effects and contraindications, even though it is a naturally occurring hormone.☐ I have disclosed all of my current medical conditions, medications, supplements, and allergies, and I understand that withholding this information may jeopardize my safety and may waive certain claims.☐ I will not share this medication with any other person, and will keep it secured out of reach of children and pets.☐ I will contact Dr. David Mahjoubi promptly if I experience any new or worsening symptoms after using this medication.☐ I am at least 18 years of age.
*
If you have any medication allergies, please write them in the box below. If none please write "none."
*
Are you currently pregnant, trying to become pregnant, or breastfeeding? Or, if applicable, is there any chance you could become pregnant during the time you would be using this medication?
*
No
Yes
Do you have any of the following heart or blood pressure conditions: high blood pressure, low blood pressure, irregular heartbeat or arrhythmia, history of heart attack, heart failure, fainting episodes, or any other cardiovascular disease?
*
No
Yes
Unsure
Have you ever been diagnosed with, or do you currently have, any of the following: schizophrenia, schizoaffective disorder, bipolar disorder, psychotic episodes, severe borderline personality disorder, or any other psychiatric condition for which you are currently hospitalized or in crisis treatment?
*
No
Yes
Do you have any of the following: kidney disease, low sodium levels (hyponatremia), syndrome of inappropriate antidiuretic hormone (SIADH), or have you ever had seizures related to fluid or electrolyte imbalance?
*
No
Yes
Are you allergic to oxytocin, chlorobutanol, or any preservative or excipient commonly used in compounded nasal sprays? Have you ever had a severe reaction (rash, swelling, breathing problems) to a nasal spray or compounded medication?
*
No
Yes
Are you currently taking any of the following medications? Mark all that apply.
*
Please Select
Migraine medication with ergot or ergotamine
Lithium
Vasoconstrictors or decongestant
Diuretics or "water pill"
None of the above
Do you have any current nasal or sinus conditions, including chronic rhinitis, nasal polyps, deviated septum, recent nasal surgery (within the past 6 months), frequent nosebleeds, or active sinus infection?
*
No
Yes
Have you ever been diagnosed with a substance use disorder, or are you currently in active treatment or recovery for alcohol or drug dependency?
*
No
Yes in the past
Yes currently
Prefer not to answer
My Products
*
prev
next
( X )
Oxytocin Nasal Spray
100 Units per mL. Total 24 mL.
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Continue
Continue
Should be Empty: