Medical Clearance Consent & Questionnaire

Telemedicine/GFE Informed Consent

Telemedicine Informed Consent: This document serves as informed consent for a telemedicine patient encounter and outlines the specific rights and responsibilities associated with this form of healthcare. Telemedicine is a type of care delivery that uses modern technologies, such as telecommunications technology, to provide remote healthcare services to patients who may otherwise lack access to conventional in-person care. The purpose of this consent form is to ensure that all participants are aware of their rights and responsibilities associated with the telemedicine encounter. Please read the following information carefully before signing below. By signing this consent form, you acknowledge that you have fully reviewed and understand the risks, benefits, and alternatives associated with telemedicine encounters. You further acknowledge that you understand the potential implications of participating in a telemedicine encounter, including but not limited to:

• Your provider will be using audio/video technology to assess your medical condition during your appointment;
• The quality of the audio/video communication may be compromised due to technical limitations or other factors beyond our control;
• There is no guarantee that any confidential medical information shared during the telemedicine encounter will remain secure;
• Neither party has an obligation to continue participation in a telemedicine encounter if either party deems it necessary for safety reasons;
• You have the right to discontinue participation in the telemedicine encounter at any time without consequences or penalty.

In addition, by agreeing to participate in a telemedicine encounter, you agree not to hold your provider liable for any damages resulting from technical malfunctions or other issues beyond their control. Furthermore, you acknowledge that it is solely your responsibility to take reasonable steps towards protecting yourself from data breaches or unauthorized access when engaging in a telemedicine session (e.g., accessing your account via password-protected resources). We thank you for taking part in this important research into new ways of delivering healthcare services more efficiently and effectively. By signing below, I confirm that I have read and understand all of the above statements regarding my rights and responsibilities pertaining to participating in a telemedicine patient encounter. I also confirm my agreement with these statements as well as my willingness to participate in this research endeavor wholeheartedly.

Disclaimer and Release of Medical-Legal Liability for obtaining a “Good Faith Exam” via a digital health apparatus. This tele-medical evaluation is not intended to be construed as a general or complete medical examination. It is for the purposes of establishing a relationship with the medical director who is a licensed physician providing supervision of the med spa you are attending. Kindly understand that this consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. Kindly understand that there are certain limitations to the use of the app to meet your doctor. If at any time you would like to speak to the doctor on the phone, through videoconferencing, at an in person appointment, or for a follow up visit, please let your staff member know and we will arrange for this for you. You always have the right to see the physician and the physician is always on standby to take care of your needs! I understand that others may also be present during the consultation other than my health care provider and the Consulting health care provider in order to operate the application. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time. In an emergent consultation, I understand that the responsibility of the telemedicine provider is to notify local emergency response systems and that their responsibility will conclude upon the termination of the video conference connection. I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby consent to participate in a telemedicine visit under the terms described herein. I, the undersigned patient, hereby declare that all of the information I am providing today to be true and correct.

HIPAA Compliance Document Informed Consent

We are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective May 31st, 2017 and applies to all protected health information as defined by federal regulation.

Uses and Disclosures: We use your health information to document and plan treatment, progress, planning, etc. We use your health information for payment. For instance, we may need to send health information including procedures done and diagnoses to your insurance company. We use your health information for regular health operations. For example, our compliance officer regularly chooses medical records for audits. This practice ensures that we are constantly working towards improved quality and effectiveness. There are services provided in our organization through contacts with business associates. Examples include outside labs, x-ray, and transcription services. We may use or disclose information to notify or assist in notifying a family member, personal representative, or other person responsible for your care, your location, and general condition.

Patient Financial Responsibility Agreement/Refund Policy

Patient Financial Responsibility Agreement: Your photo-identification will be photocopied and stored in your medical record for your protection and security. This account is self-pay, and payment in full is due at the time of each service. I clearly understand and agree that all services rendered to me may be charged directly to me, and that I am personally responsible for full payment. I understand that even if I suspend or terminate treatment, any fees for professional services rendered to me or to my dependent up to the point of termination will be immediately due and payable. I acknowledge that I am responsible for any outstanding fees for services provided to me by the clinic. Any other arrangements that may involve a payment plan or payment deferral of any kind must be made in writing with the office manager or business manager of the Practice. Verbal agreements are not acceptable or binding. I acknowledge that the Practice reserves the right to charge a fee if I fail to attend or cancel the scheduled appointment without providing the Practice 24-hour prior notice. I further acknowledge that the Practice reserves the right to reschedule my appointment if I am more than 15 minutes late to a scheduled appointment.

Peptide Therapy Disclaimer & Consent

IMPORTANT: PLEASE READ CAREFULLY By purchasing or receiving peptide therapy, you acknowledge and agree to the following terms: 1. Research and Development (R&D) Use Only: The peptides used in our therapies are classified as Research and Development (R&D) substances. They are intended to stimulate the body’s natural hormone production and may not be approved by the FDA for all uses. These peptides are not FDA-approved for direct use in clinical applications such as anti-aging or body composition improvement. However, they are widely used off-label for their potential benefits in growth hormone stimulation and other therapeutic effects.

2. Off-Label Use: Peptide therapy is considered off-label by the FDA when used for purposes other than the indications for which they were originally developed. We prescribe these peptides under the guidance of licensed medical professionals in compliance with state laws. Your healthcare provider has determined that peptide therapy may benefit your health needs based on your medical history, assessment, and clinical evaluation.

3. Individual Results May Vary: The effectiveness of peptide therapy varies from patient to patient. Not all individuals will experience the same benefits or results. The use of peptide therapy should be discussed in detail with your healthcare provider to ensure that it is appropriate for you.

4. Potential Side Effects: As with any therapy, peptides may cause side effects, including but not limited to headaches, fatigue, nausea, or localized injection site reactions. These effects may be temporary or require adjustments to your dosage or therapy schedule. Please discuss potential risks with your healthcare provider.

5. Medical Clearance Requirement: Medical clearance is required prior to the initiation of peptide therapy. The cost of medical clearance is $130. Medical clearance is valid for six (6) months from the date of evaluation. Any medical conditions or concerns must be discussed with your provider prior to initiating therapy.

6. Patient Responsibility: You acknowledge that you are responsible for following all instructions provided by your healthcare provider and for attending all follow-up appointments. You agree to notify your healthcare provider of any adverse reactions or concerns immediately.

7. Liability Release: By signing below, you release the company, its affiliates, and healthcare providers from any liability associated with peptide therapy, including but not limited to misuse, side effects, or adverse reactions.