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 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”).
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.
By submitting this refill request, I authorize InfusaLounge Allen PLLC and InfusaLounge Wellness Spa, LLC, DBA InfusaLounge Integrative & Functional Medicine, to collect payment according to my selection above: either by charging my card on file upon provider approval, or by sending me a secure payment link, and I understand that my medication will ship only after 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.
