Start At-Home Therapy

TELEMEDICINE PATIENT CONSENT. PURPOSE: The "Telemedicine Consent Form" aims to get the patient's consent to participate in telemedicine appointments with the provider. RECORDS: Telecommunications with patients will not be recorded and stored. Patient's medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies.

TELEMEDICINE INFORMATION: The medical information related to the patient's history, records, and tests will be discussed during the telemedicine appointment with video and audio. ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment.

PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask questions related to telemedicine appointments and technical requirements for telecommunication.

PRIVACY: By signing this form, I understand that all the laws that protect my privacy of medical history or information are also applied to telemedicine practices. I acknowledge that I have been provided access to InfusaLounge's Notice of Privacy Practices, and that my acceptance below serves as my electronic acknowledgment of that notice. I understand that I can withdraw the consent at any time, which will not affect my future treatment procedures. I understand that I can be charged additional fees that my insurance does not cover. I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis. All Sales are Final. No Refunds will be processed unless you are not a candidate for the therapy. The Pharmacy will not take the Medication back. I seek the medical services of InfusaLounge Allen PLLC and their employees/contractors (collectively InfusaLounge Wellness Spa). I am executing this consent to confirm my understanding of the risks, benefits, and alternatives to treatment with peptide therapy. The goal and possible benefits of this therapy are to prevent, reduce or control the dysfunction associated with the aging process through hormone balancing, control of oxidative stress and other clinically significant therapeutic agents. However, I understand that this treatment may be viewed by the mainstream medical community as new, controversial, off-label, experimental, and unnecessary by the Food and Drug Administration (“FDA”).

RELEASE: I agree to release InfusaLounge Wellness Spa LLC, its employees or contractors from all liability, of adverse effects with previously used Semaglutide/Tirzepatide or other peptide therapies, that were not prescribed by InfusaLounge Wellness Spa LLC and/or current Semaglutide/Tirzepatide and/or peptide therapy prescriptions ordered by InfusaLounge Wellness Spa, LLC. All Medical History know or not know that is not disclosed to the provider at the time of consultation. All changes in medical history must be reported to the provider on the monthly progress refill form. There are no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned medication.

PAYMENT: I understand that a $75 consultation fee applies for the provider's time for weight loss and peptide consultations, and that this fee is not applied toward the cost of medication. I understand that payment for medication is collected after my consultation and provider approval, by secure payment link or as arranged with the InfusaLounge team, and that my medication will ship only after my consultation is complete and payment is received. I acknowledge that all sales are final and charges are non-refundable once the medication order has been submitted to the pharmacy.