CJC-1295 / Ipamorelin – 7.2mg / 15mg

Telehealth Treatment Consent and Acknowledgment

This Consent and Acknowledgment (“Consent”) is entered into between NYC Infusion (“Practice,” “we,” “us,” or “our”) and the undersigned patient (“you” or “your”).

By signing below, you acknowledge and agree to the following:

1. Consent to Evaluation and Treatment

You consent to receive telehealth healthcare services from NYC Infusion and its licensed healthcare providers, including physicians, nurse practitioners, physician assistants, and other authorized clinical personnel acting within the scope of their licensure and responsibilities.

Services may include, as clinically appropriate:

-telehealth medical evaluation
-review of symptoms and medical history
-treatment planning
-laboratory review, if applicable
-prescription evaluation, if clinically appropriate
-follow-up care and ongoing clinical monitoring

You understand that all treatment recommendations are based on your individual health history, symptoms, goals, and provider assessment.

2. Nature of Telehealth Services

Telehealth involves the use of electronic communications and technology to enable a healthcare provider to evaluate, assess, monitor, and communicate with you remotely.

You understand that telehealth services may include:

-review of submitted health information
-electronic or virtual communication with a licensed provider
-discussion of symptoms, treatment options, and follow-up recommendations
-clinical decision-making based on the information you provide and other available records, if applicable

You understand that telehealth services may have limitations compared to in-person evaluation and may not be appropriate for every medical condition or concern.

3. No Guarantee of Results

You understand that healthcare services do not guarantee any particular result or outcome. Individual responses to treatment vary, and no promise or guarantee has been made regarding the effectiveness of any evaluation, treatment plan, recommendation, or therapy.

4. Risks and Limitations of Telehealth

You understand that telehealth services carry certain limitations and risks, including but not limited to:

-limitations in the ability to perform a physical examination
-incomplete or inaccurate information provided by the patient
-technical difficulties, interruptions, or communication failures
-limitations in the ability to diagnose or treat certain conditions remotely
-the possibility that telehealth may not be appropriate for your needs

You understand that if your provider determines telehealth is not appropriate for your condition, you may be advised to seek in-person medical care, emergency care, or additional evaluation.

5. Prescription and Treatment Decisions

You understand that any treatment recommendation, including any prescription recommendation, is based solely on provider evaluation, clinical judgment, medical appropriateness, and applicable laws and regulations.

You understand that:

-a prescription is not guaranteed
-not all patients will be appropriate candidates for treatment
-treatment continuation is subject to ongoing provider review and clinical appropriateness
-laboratory testing or additional evaluation may be required before or during care

6. Alternatives to Telehealth Treatment

You understand that alternatives may include:

-no treatment
-in-person evaluation by a healthcare provider
-consultation with another medical professional
-emergency or urgent care services where appropriate

You acknowledge that you have the right to decline or postpone treatment.

7. Health Information and Patient Responsibility

You certify that, to the best of your knowledge, the health information you provide to the Practice is complete and accurate, including:

-your medical history
-current symptoms
-allergies or sensitivities
-medications or supplements
-prior diagnoses or treatment history

You understand that incomplete or inaccurate information may affect the safety, appropriateness, or availability of care.

You agree to promptly notify the Practice of any changes in your health status, medications, allergies, pregnancy status, or other relevant medical information.

8. Opportunity to Ask Questions

You acknowledge that you have had the opportunity to ask questions regarding telehealth services and any recommended treatment, and that your questions have been answered to your satisfaction.

You understand that you may ask additional questions at any time before proceeding with care.

9. Voluntary Consent

You acknowledge that your decision to receive telehealth services is voluntary and that you may decline or discontinue care at any time, subject to provider recommendations related to safety and continuity of care.

10. Consent to Participation of Clinical Personnel

You understand that your care may involve licensed clinical personnel and authorized support staff acting within the scope of their role and responsibilities.