I request a telemedicine evaluation for wellness, weight management, metabolic support, and/or peptide therapy. I understand that telemedicine uses secure electronic communication to evaluate, counsel, and treat patients without an in-person visit.

‎‎

I understand that telemedicine has benefits, including convenience and access from a distance, but may also have limitations because my provider cannot perform a complete physical exam in the same way as an in-person visit. I understand that my provider may request records of lab work, blood pressure readings, photos, weight records, or other information before starting or continuing treatment.

‎‎

I understand that peptide therapy is part of a medically supervised wellness plan intended to support specific health goals such as weight management, recovery, vitality, sleep, body composition, sexual wellness, or aesthetic support.

‎‎

I understand that peptides are signaling molecules used to stimulate existing  biological functions in the body. I understand that treatment recommendations are individualized.

‎‎

I understand that treatment may include GLP-1 medications such as semaglutide or tirzepatide, as well as peptide therapy or related wellness protocols, depending on my clinical evaluation and provider judgment. I understand that some therapies may be prescriptions, compounded, or prescribed off-label depending on the medication and my treatment plan

‎‎

I understand that potential benefits may include support for weight management, appetite regulation, blood sugar control, metabolic optimization, or other wellness goals. I understand that no  specific result is guaranteed and that results take time. I understand that my results are also dependent on me following provider health habit recommendations.

‎‎

I understand that potential side effects or risks may include nausea, vomiting, diarrhea, constipation, abdominal discomfort, headache, fatigue, dizziness, appetite change, injection-site reactions, allergic reactions, dehydration, and other medication-specific risks. I understand that more serious complications may occur depending on the medication, dose, my medical history, and my compliance and response to prescribed treatment.

‎‎

I agree to provide complete and accurate information about my past and current medical history, surgical history, family history, current medications, supplements, allergies, pregnancy or breastfeeding status, recent lab work, and any history of cancer, unexplained masses, tumors, pancreatitis, gallbladder disease, thyroid disease, cardiovascular disease, kidney disease, liver disease , severe organ impairment, diabetes, or other significant health concerns. I understand that failure to disclose important information may increase risk and may affect my treatment eligibility.

‎‎

I understand that I may not be a candidate for treatment if have certain contraindications or safety concerns, including but not limited to pregnancy, breastfeeding, active cancer, unexplained masses, tumors, sever organ impairment, or other conditions identified by my provider.

‎‎

I agree to follow all dosing instructions exactly as prescribed, attend scheduled follow up visits, complete lab testing when requested, report side effects promptly, and use the medication only as directed. I understand that treatment outcomes depend in part on adherence to the overall plan, including diet, exercise, hydration, sleep, and other lifestyle recommendations.

‎‎

I understand that telemedicine if not appropriate for emergencies. If I experience severe symptoms such as chest pains, trouble breathing, swelling of the face or throat, severe abdominal pain, fainting, severe vomiting, or signs of serious allergic reaction, I will call emergency services or seek immediate in-person care.

‎‎

I understand that some peptide therapies may be compounded, prescribed off-label, or used in a manner that is not FDA-approved for a specific indication.

‎‎

By signing below, I acknowledge that I have read and understood this form, had the opportunity to ask questions, and voluntarily consent to telemedicine evaluation and treatment for GLP-1 and/or peptide therapy.