Waiver, Terms of Service &
Telehealth Informed Consent
Please read this document carefully. Before booking a video consultation, you will be asked to sign this waiver by checking the consent box on the booking form.
Effective Date: August 15, 2026
By checking the waiver consent box on the consultation booking form, you are electronically signing this document. This constitutes a legal signature and binding agreement to the terms below.
Peptide Therapy Treatment Waiver
I, the undersigned, acknowledge and agree that I am choosing to participate in peptide therapy administered or supervised by the clinical team. I understand that peptides are a class of amino acids that may be used for various therapeutic purposes.
I understand that while many peptides have shown promise in research and clinical settings, some may be considered "investigational" or used "off-label" in the context of my specific treatment. I acknowledge that the long-term effects of some peptide therapies may not be fully understood.
I have been informed of the potential risks and benefits associated with my treatment plan. I agree to hold the clinical team, the medical practice, and all associated staff harmless from any adverse reactions, side effects, or complications that may arise from the use of prescribed peptides. I certify that I have disclosed my full medical history and current medications to my provider.
Terms of Service
1. Service Agreement: By accessing our services, you agree to comply with all protocols established by the medical practice.
2. Payments: All payments for consultations, lab work, and medications are due at the time of service. No refunds are provided for services rendered.
3. Communication: You agree to maintain current contact information and respond to inquiries from the medical team in a timely manner.
4. Prescriptions: Medications are for the exclusive use of the patient to whom they are prescribed. You agree not to share, sell, or distribute any medications provided to you.
5. Termination: The practice reserves the right to terminate the patient-provider relationship at any time for non-compliance with treatment protocols, abusive behavior, or failure to adhere to office policies.
Informed Consent for Telehealth Services
Telehealth involves the delivery of health care services using electronic communications, information technology, or other means between a provider and a patient who are not in the same physical location.
Potential Benefits:
- Improved access to medical care by enabling me to consult with my provider without traveling to the office.
- Efficient evaluation and management of my treatment plan.
Potential Risks:
- As with any medical service, there are potential risks associated with the use of telehealth, including interruptions in service, technical difficulties, or unauthorized access to private information.
- I understand that if the provider determines that the telehealth visit is not sufficient for my medical needs, I may be required to seek in-person medical attention.
Confidentiality:
The electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data.
Patient Acknowledgement:
I have had the opportunity to discuss the information above with my provider and have had all of my questions answered to my satisfaction. I voluntarily consent to participate in telehealth services and assume all risks associated with the use of this technology.
No printed signature is required. By checking the consent box on the consultation booking form, you sign this agreement electronically and it is recorded with your submission.
Questions About This Waiver?
Contact our team before proceeding with any services.