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DRAFT — not approved for clinical use

Practice legal name, address, responsible clinician, state-specific provisions, routine contact method and response times must be completed before use. This is a draft for adult patients; minors and authorized representatives require separate review.

I request a medical evaluation. My clinician will discuss the proposed treatment, its purpose, expected benefits, material risks, reasonable alternatives and the option of no treatment. Outcomes cannot be guaranteed. A consultation does not guarantee a prescription or a particular medication.

I will provide accurate health history, allergies, medications and supplements, prior reactions, pregnancy or breastfeeding status when relevant, and changes in my health. I understand that examination, testing, referral or an in-person visit may be necessary. I may ask questions, refuse a treatment, or stop future treatment after discussing a safe plan.

Before any specific treatment, my clinician and I will record: diagnosis or reason for care; proposed product/procedure and route; expected benefits; patient-specific risks and contraindications; alternatives; tests and monitoring; instructions; follow-up date; and urgent warning signs. Additional treatment-specific consent is required when appropriate.

I will use only the prescribed product and instructions, avoid sharing medication, and contact the practice about side effects or uncertainty. This practice is not an emergency service. I will call 911 or seek emergency care for a life-threatening problem. The clinician must provide the appropriate routine and urgent contact pathway before treatment.

My signature documents a voluntary decision after an opportunity to ask questions. It does not waive legal rights or release the practice from responsibility for negligent care.

Information required before signing

• Patient name and date of birth
• Clinician and diagnosis / proposed treatment
• Patient-specific discussion and questions answered
• Routine contact, response time, follow-up and urgent plan
• Patient or authorized representative signature, relationship and date/time
• Clinician confirmation of discussion, signature and date/time

Preview only. No signature is captured and no document is sent from this page.

DRAFT — not approved for clinical use

Telehealth uses electronic communication for a clinical visit. It can improve access, but a remote examination may be limited. Connection failures, poor audio/video, or incomplete information can affect evaluation; an in-person visit, testing, referral or rescheduling may be needed.

I will identify myself and provide my actual physical location, state, callback number and local emergency contact at each visit. Care may proceed only when the clinician is legally authorized to practice for my location and the visit is clinically appropriate. Availability across all states is not guaranteed.

I will join from a private location using a suitable device and connection. Privacy and security risks remain despite safeguards. I will identify anyone present. The clinician will identify participants and obtain permission for additional observers. Recording requires a separate agreement and any legally required consent.

I may decline telehealth or withdraw consent for future remote visits and discuss available alternatives and related fees. If the connection fails, the clinician and I will use the agreed callback or rescheduling plan. Telehealth is not an emergency service; call 911 for emergencies.

The clinician will explain the visit, answer questions and document the state-specific consent requirements. Signing this form does not replace that discussion.

Information required before signing

• Patient name and date of birth
• Visit location / state, callback number and emergency contact (verify each visit)
• Clinician identity and licensed / authorized location
• Platform, backup connection plan and alternatives discussed
• Participants and interpreter if applicable
• Patient or representative signature and date/time
• Clinician consent confirmation and date/time

Preview only. No signature is captured and no document is sent from this page.

DRAFT — not approved for clinical use

Before activation, the practice must disclose the exact records covered, the secure portal, how to request paper records or withdraw electronic-delivery consent, any applicable fees or consequences, and how to update contact information. Fill these details below; do not use an incomplete form.

I may choose electronic records and signatures for intake, consent and related care documents, or ask about the paper option. Consent to electronic delivery is separate from consent to medical treatment and is not consent to marketing. Withdrawal applies prospectively and does not invalidate earlier records.

To use electronic records I need the vendor's supported browser/device, internet access, a verified account and the ability to open, save or print the supplied file format. The practice will identify these requirements and provide an access test before asking me to consent. If material access requirements change, the practice will provide the required notice and obtain renewed consent when required.

Completed documents should be available to me through my secure account and to authorized practice staff. I can save or request a copy. Email or text alerts may say a document is ready without including health details; shared devices, wrong addresses and forwarded notifications can create privacy risks.

I may request reasonable confidential communication alternatives. Unencrypted email can expose information to others. If I request that method, the practice will explain the risks, verify the address and document my choice and safeguards separately. Do not assume this consent authorizes unrestricted health information by ordinary email.

Information required before signing

• Patient name
• Scope of records and secure portal / file format
• Hardware/software access requirements and successful access test
• Paper-copy request method, fees if any, withdrawal method and consequences
• Verified notification destination and confidential communication preference
• I choose electronic records / I request the paper option (select one)
• Patient or representative signature and date/time
• Exact disclosure version and practice confirmation

Preview only. No signature is captured and no document is sent from this page.

DRAFT — not approved for clinical use

I acknowledge that I received or was offered the practice's completed Notice of Privacy Practices, identified below, and a way to obtain another copy. That notice describes applicable uses and disclosures, patient rights and the privacy contact.

This acknowledgment confirms receipt. It is not a blanket authorization to release my records, consent to marketing, or a waiver of privacy rights. A separate valid authorization is used when required.

If I do not sign, the practice should document its good-faith effort and the reason an acknowledgment was not obtained. The practice must supply its actual, current notice before using this acknowledgment; this page is not that notice.

Information required before signing

• Patient name
• Practice legal name and privacy contact
• Notice title, effective date, version and delivery method
• Patient or representative signature and date
• Staff documentation of receipt / good-faith attempt if not signed

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DRAFT — not approved for clinical use

Record the exact medication, manufacturer or compounding pharmacy, formulation, route, intended use and prescribing-information version. This draft focuses on semaglutide/tirzepatide risks and must be adapted to the actual product. Different drugs require different consent. My clinician will discuss whether the use is FDA-approved for the product and indication, off-label, or compounded.

Potential benefits and alternatives depend on my diagnosis. Alternatives may include nutrition and activity support, other medication, referral, or no medication. Benefits are not guaranteed. I understand follow-up, monitoring and ongoing costs are part of the decision.

Common reactions can include nausea, vomiting, diarrhea, constipation and abdominal discomfort. Serious risks can include pancreatitis, gallbladder problems, severe gastrointestinal effects, dehydration with kidney injury, allergic reactions, and low blood sugar particularly with certain diabetes medicines. Other product-specific risks must be reviewed.

For products with a thyroid C-cell tumor warning, my clinician will review that warning and screen for personal/family history of medullary thyroid carcinoma or MEN 2 and applicable contraindications. We will also review pregnancy plans, breastfeeding, gastrointestinal disease, kidney problems, other medicines and previous reactions. Tirzepatide can affect oral contraceptive effectiveness during initiation and dose increases; my clinician will explain the labeled precautions.

I will tell anesthesia/procedure teams about this medication because delayed stomach emptying can affect procedural risk. My clinician will provide product-specific pregnancy/discontinuation guidance, instructions for missed doses, storage and administration, and when to seek help. I will not adjust doses or combine products without instructions.

I understand this is not the full risk list. I received the applicable Medication Guide/prescribing information, had questions answered and understand my individualized plan. A compounded product requires the separate compounded-medication disclosure as well.

Information required before signing

• Patient name and date of birth
• Exact product, source, formulation, route and intended use
• Approval / off-label / compounded status and Medication Guide version supplied
• Contraindication screening and individual risks discussed
• Alternatives, expected benefits, costs and monitoring plan
• Administration teaching, warning signs and follow-up contact
• Patient or representative signature and date/time
• Clinician discussion confirmation and date/time

Preview only. No signature is captured and no document is sent from this page.

DRAFT — not approved for clinical use

Record the exact ingredients, concentration, dosage form, route, dispensing pharmacy and patient-specific reason for compounding. A compounded drug is not FDA-approved; FDA does not review its safety, effectiveness or quality before marketing. It is not automatically equivalent to an FDA-approved product.

Possible additional risks include contamination, incorrect strength, stability problems, administration errors, and uncertainty about evidence or interactions, especially for combinations. Adding vitamins or other ingredients does not establish improved safety or effectiveness.

My clinician will explain why an available approved product does not meet my clinical need, the lawful basis for this preparation and applicable alternatives. Cost or supplier availability alone does not establish that a preparation is legally permissible. The practice and pharmacy must verify applicable federal and state requirements independently.

I will receive the pharmacy label, storage instructions, beyond-use date, exact administration instructions and teaching with any required supplies. Vial strength is not the prescribed dose. I will ask before use if the label or instructions are unclear, or if the product appears altered.

This consent does not authorize investigational or research-only compounds for routine treatment and does not override compounding restrictions. If a proposed preparation is not lawful or appropriate, it must not be prescribed through this process.

Information required before signing

• Patient name
• Exact ingredients, concentration, dosage form, route and pharmacy
• Clinical reason approved alternatives do not meet this patient's need
• Documented legal / pharmacy verification (practice field)
• Evidence limitations, risks, alternatives and monitoring discussed
• Label, storage, beyond-use date and administration teaching supplied
• Patient or representative signature and date/time
• Prescriber confirmation and date/time

Preview only. No signature is captured and no document is sent from this page.

DRAFT — not approved for clinical use

My clinician will record the exact ingredients, amounts, route, medical purpose, source and plan. Evidence and approval status depend on the product and indication. This consent makes no promise of detoxification, anti-aging, increased energy, immunity or disease prevention.

Risks can include pain, bruising, bleeding, infection, vein irritation or clotting, leakage into surrounding tissue, fainting, allergic reactions including anaphylaxis, medication interactions, fluid overload, and electrolyte or other metabolic disturbances. Specific ingredients and my health history may create additional risks.

We will review allergies, medication/supplement use, prior reactions, pregnancy or breastfeeding, kidney or heart conditions and other relevant history; testing may be necessary. Reasonable alternatives can include oral hydration/nutrition, evaluation of underlying symptoms, another treatment or no procedure.

I understand the clinician must decide whether the procedure is medically appropriate. Trained staff, appropriate monitoring and a response plan for complications are required. I can ask to stop; staff will explain how to stop safely.

I will receive aftercare instructions, expected effects, warning signs, contact information and follow-up. I will seek emergency care for severe symptoms such as trouble breathing, chest pain or a serious allergic reaction.

Information required before signing

• Patient name
• Exact procedure, ingredients/amounts, route, source and medical reason
• Screening, tests, patient-specific risks and alternatives
• Monitoring, emergency response and aftercare plan
• Expected costs and follow-up
• Patient or representative signature and date/time
• Clinician procedure discussion confirmation and date/time

Preview only. No signature is captured and no document is sent from this page.

DRAFT — not approved for clinical use

Before signing, the practice must supply actual evaluation, medication, dispensing, lab, follow-up and procedure charges as applicable, insurance/self-pay status, cancellation/refund terms, and any recurring-payment terms. Supplier wholesale prices are not patient prices.

If I am uninsured or choose not to use insurance, I may be entitled to a written good faith estimate when scheduling eligible care or requesting an estimate. This acknowledgment does not replace that estimate or its required disclosures.

If a qualifying bill from a provider is at least $400 above that provider's good faith estimate, a federal patient-provider dispute process may be available. The practice will provide the applicable CMS notice and information, including deadlines. Signing does not waive those rights.

I understand the documented charges and have had questions answered. Authorization for recurring charges, if offered, must separately state the amount, frequency, cancellation method and applicable terms; it is not inferred from this acknowledgment.

Information required before signing

• Patient name
• Insurance / self-pay status and actual fee schedule supplied
• Good faith estimate identifier, date, expected services and total
• CMS rights notice supplied and questions answered
• Cancellation / refund terms, version and delivery method
• Patient or representative signature and date
• Staff confirmation and date

Preview only. No signature is captured and no document is sent from this page.

DRAFT — not approved for clinical use

The practice must identify the disclosing party, recipient, specific information, purpose and expiration date/event below. Do not use a blank, unlimited authorization. Certain sensitive records require additional legal review and specialized provisions.

I understand I can revoke this authorization in writing through the stated method, except to the extent action has already been taken in reliance on it. Disclosures to a recipient not bound by applicable privacy rules may be redisclosed and may no longer be protected by those rules.

Unless a lawful exception applies, treatment, payment, enrollment or benefit eligibility is not conditioned on signing this authorization. It does not authorize marketing, sale of information or research unless separately and expressly addressed through the required process.

I may receive a copy of the signed authorization. A representative must identify their authority to act. The practice must complete its contact and revocation instructions and review all required elements before use.

Information required before signing

• Patient name and date of birth
• Party authorized to disclose and recipient name/contact
• Specific records / date range and exclusions
• Purpose of disclosure
• Expiration date or event
• Revocation method and practice contact
• Patient or representative signature, authority and date
• Copy provided and practice review confirmation

Preview only. No signature is captured and no document is sent from this page.