Medical & Telehealth Consent

This Medical and Telehealth Consent ("Consent") describes the nature, benefits, risks, limitations, and alternatives of receiving medical care through My4MLife's telehealth platform. Please review this Consent carefully before your appointment.

1. Consent to Telehealth Services

I voluntarily consent to receive healthcare services from a licensed provider through My4MLife's telehealth platform. I understand telehealth involves the use of electronic communications, including secure video, audio, and messaging, to enable a provider at a remote location to evaluate, diagnose, and treat me without an in-person visit.

2. Nature of Telehealth

Benefits

• Convenient access to medical care from my home
• Reduced travel and waiting time
• Access to specialists who may not be available locally
• Ongoing monitoring and support between visits

Limitations

• The provider may not be able to perform physical examinations typical of in-person visits
• Diagnosis may be limited by the quality of the video or audio connection
• Certain conditions may require in-person evaluation or diagnostic testing
• Technical failures or equipment issues may occur
• Telehealth is not equivalent to traditional in-person care in all situations

3. GLP-1 Medication Risks and Side Effects

I understand that GLP-1 receptor agonist medications (such as semaglutide and tirzepatide) may cause side effects and carry certain risks:

4. Compounded Medication Disclosure

I understand that My4MLife may prescribe compounded medications. Compounded medications:

• Are prepared by state-licensed compounding pharmacies using FDA-regulated ingredients
• Are not individually FDA-approved (the individual product is not reviewed for safety, efficacy, or quality by the FDA)
• Are legally prescribed when a licensed provider determines they are medically appropriate
• May contain the same active ingredients as brand-name medications but in different strengths, formulations, or combinations

5. Patient Responsibilities

As a patient, I agree to:

• Provide complete, accurate, and truthful medical history and health information
• Disclose all current medications, supplements, allergies, and existing medical conditions
• Follow the treatment plan as prescribed by my provider
• Promptly report any side effects, adverse events, or changes in my health
• Attend scheduled follow-up appointments and complete required lab work
• Store and use medications as directed
• Contact my provider before discontinuing or changing any medication

6. Emergencies

7. Right to Withdraw Consent

I understand that I may withdraw my consent to telehealth services at any time, without affecting my right to future care. I can choose to discontinue treatment or request a referral to an in-person provider. Withdrawal of consent does not affect services already provided.

8. Privacy and Confidentiality

My health information will be handled in accordance with HIPAA and the My4MLife Privacy Policy. Telehealth communications are conducted through encrypted, HIPAA-compliant platforms. I understand that no method of electronic transmission is 100% secure, though reasonable safeguards are in place.

9. Photo and Communication Consent

I consent to my provider recording or documenting our consultations in my medical record. I may be asked to provide photos (e.g., injection site, skin conditions) to support my care. Any such images are treated as PHI and protected accordingly.

10. Financial Responsibility

I understand that My4MLife services are paid out-of-pocket and are not typically covered by insurance. I am responsible for all charges associated with my care, medications, and shipping. Fees are disclosed before any charge.