Atlanta Weight Loss and HRT
Telehealth Medical Consent

2. Consent to Treatment

I, the undersigned, consent to participate in medical treatment provided by Atlanta Weight Loss and HRT, including GLP-1 compounded weight loss medications and hormone replacement therapy (HRT). I acknowledge that:

• I understand that I have voluntarily chosen to seek these medical treatments.

• I understand that the treatments involve the use of GLP-1 compounded medications for weight loss and/or hormone replacement therapy to address hormonal imbalances or deficiencies.

• I understand the purpose, benefits, and nature of the treatment, as well as any potential alternatives.

3. Telehealth Services Consent

• I understand that telehealth involves the use of electronic communications to enable healthcare providers at different locations to share my medical information for the purpose of improving my care.

• I understand that telehealth services may include live two-way audio and video, and the electronic transmission of my health records and other patient data.

• I understand that telehealth services are not the same as in-person services and have limitations, including potential technical difficulties and risks of unauthorized access.

4. Risks and Benefits

• I understand that as with any medical treatment, there may be potential risks and side effects associated with GLP-1 compounded medications and HRT. These risks may include nausea, dizziness, headaches, allergic reactions, and other adverse effects.

• I understand the potential benefits of the treatment, which may include weight loss, improved metabolic function, and relief of symptoms related to hormone deficiencies.

• I understand that I have the opportunity to ask questions and have received satisfactory answers regarding the treatment, its risks, and benefits.

5. Confidentiality and Privacy

• I understand that my health information will be kept confidential and will only be shared in accordance with the law and company policies.

• I understand that while Atlanta Weight Loss and HRT takes steps to secure electronic communications, there is a risk of unauthorized access when using telehealth platforms.

6. Acknowledgment of Financial Responsibility

• I understand that I am financially responsible for the costs associated with the treatments I receive, including telehealth consultations, medications, and follow-up appointments.

• I understand that Atlanta Weight Loss and HRT may not bill insurance for these services and that it is my responsibility to arrange payment.

7. No Guarantee of Results

• I understand that Atlanta Weight Loss and HRT cannot guarantee specific results from my treatment and that outcomes may vary depending on individual circumstances.

8. Consent to Communication

• I understand that I may receive communications from Atlanta Weight Loss and HRT via email, phone, or other means for appointment reminders, treatment updates, and other relevant information.

9. Right to Withdraw

• I understand that I have the right to withdraw my consent to participate in these treatments at any time, without affecting my right to future care or treatment.

10. Consent to Use and Disclosure of Information

• I understand that my health information might be shared under certain circumstances, such as with other healthcare providers, for billing purposes, or as required by law.

• I consent to these disclosures as described above.

11. Alternative Treatments

• I understand that there are alternative treatments available for weight loss and hormone imbalances and that I have the right to choose different therapies or none at all.

12. Follow-Up and Continuity of Care

• I understand the importance of follow-up care and that I may be required to have regular check-ins to monitor my progress and adjust my treatment plan as necessary.

13. Emergency Procedures

• I understand that in the event of a severe reaction or medical emergency related to my treatment, I should seek immediate medical attention and contact Atlanta Weight Loss and HRT as soon as possible.

14. Dispute Resolution and Legal Terms

• I understand the procedures for dispute resolution, including any arbitration agreements, and that the jurisdiction governing the consent form and treatment agreement is specified by Atlanta Weight Loss and HRT.

15. Consent for Participation in Research (If Applicable)

• I understand that my de-identified health data may be used for research purposes, and I consent to this use. I understand that my privacy will be protected, and participation in research is voluntary.

16. State-Specific Requirements and Legislation

• I understand that certain state-specific regulations or requirements may apply to my treatment based on my location. These may include, but are not limited to, additional disclosures, specific language, or variations in telehealth laws.

• I understand that Atlanta Weight Loss and HRT will provide information about any state-specific requirements that apply to my treatment, and these will be referenced as applicable:

  • California: In accordance with California Business and Professions Code §2290.5, I understand that I have the right to receive information about the role and credentials of the healthcare provider and the specific services provided. I also understand the right to confidentiality of my medical information as per California's Confidentiality of Medical Information Act (CMIA).

  • Florida: I understand that under Florida Statutes §456.47, telehealth services must meet the same standard of care as in-person services, and I have the right to receive information about the provider’s qualifications and the security measures in place to protect my information.

  • New York: As per New York Public Health Law Article 29-G, I understand that telehealth services are regulated to ensure quality of care and confidentiality. I acknowledge that I will be informed of any specific state requirements before the commencement of treatment.

  • Texas: I understand that under Texas Occupations Code §111.005, I have the right to know the provider's credentials, the scope of telehealth services offered, and the security protocols in place to ensure my privacy. I also understand that telehealth services in Texas are subject to state-specific laws that may affect my treatment.

• I understand and consent to comply with these state-specific requirements, as they are part of my overall treatment plan.

17. Patient Declaration of Understanding

• I understand that by signing this form, I declare that I have read and fully understood all the information provided in this consent form, including all risks, benefits, and terms of the treatment.

18. Consent Validity and Duration

• I understand that this consent remains valid unless revoked or until significant changes in my treatment plan or health condition require a new consent form.

19. Emergency Situations Disclaimer

• I understand that telehealth services provided by Atlanta Weight Loss and HRT are not intended to address emergency or life-threatening medical situations. If I am experiencing a medical emergency, I should immediately call 911 or go to the nearest emergency room.

• I understand that if I am having thoughts of self-harm, experiencing suicidal thoughts, or facing a mental health crisis, I should seek immediate help. I can contact the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) or dial 988, which is the Suicide & Crisis Lifeline, for immediate support.

• I understand that Atlanta Weight Loss and HRT telehealth services are designed for non-emergency consultations, ongoing management of chronic conditions, and follow-up care related to weight loss and hormone replacement therapy. Telehealth services cannot replace in-person emergency medical care.

• I acknowledge that it is my responsibility to use telehealth services appropriately and to seek emergency care when needed.