With my consent, Misra Wellness™, Sulagna Misra, MD and associates, may use and disclose Protected Health Information (PHI) about me to carry out Treatment, Payment and Healthcare Operations (TPO).  Please refer to Misra Wellness's ™ Notice of Privacy Practices for a more complete description of such uses and disclosures. 

 I have had the opportunity to review the Notice of Privacy Practices prior to signing this consent.  Misra Wellness™ reserves the right to revise its Notice of Privacy Practices at any time.  A revised Notice of Privacy Practices may be obtained by forwarding a written request to Sulagna Misra, MD 18740 Ventura Blvd. Suite 204, Los Angeles, CA 91356.

 With my consent Misra Wellness™ may call my home or other designated location  and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out the Treatment, Payment and Healthcare Operations (TPO), such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, Misra Wellness™ may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

With my consent, Misra Wellness™ may email to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.  I have the right to request that Misra Wellness™ restrict how it uses or discloses my PHI to carry out TPO. 

However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. 

 By signing this form, I am consenting to Misra Wellness’s™ use and disclosure of myProtected Health Information (PHI) to carry out Treatment, Payment and Healthcare Operations (TPO.)

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.  If I do not sign this consent, Misra Wellness™ may decline to provide treatment to me.

1. Medical Consent: I consent to any medical treatments or procedures which may be performed on an outpatient basis (excluding emergency treatment or services), which may include but are not limited to medications, injections, taking of medical photographs, laboratory procedures, and/or x-ray examinations provided to me under the general and special instructions of the physicians, staff, or other health care providers of Misra Wellness assisting my care.

2. Financial Obligation: I understand that all Fee For Service (FFS) charges are due at the time of service. I agree to pay Misra Wellness for all charges for healthcare services and professional services provided to me by physicians and other healthcare professionals.

3. Acceptable forms of payment include Cash, Visa, MasterCard, Discover and Debit card. I agree to pay for my visit in full at the time of service.

4. Non-Participation in Insurance.  The DPC Practice does not participate with any health plans, HMO panels, or any other third-party payor.  As such, we will not submit bills or seek reimbursement from any third-party payors for the Services provided under this Agreement. 

5. This is a Hybrid DPC-Practice which means certain insurances may be utilized outside of the care given by Misra Wellness (Hospitalizations, ER visits, blood work, Imaging Studies, etc).  However, with the DPC Membership we do NOT bill insurance and do not bill Medicare at all. As a result, you are solely responsible for any and all financial agreements in place. 

 6. Release of Medical Information: I hereby authorize Misra Wellness  to release any information in my chart to any practitioner, doctor, hospital, or medical institution to which I may be referred to assist in my care. Additionally, I authorize any request for medical information from any medical practitioner, doctor, hospital, or medical institution to assist in the care of the above-named patient.

7. The undersigned certifies that he/she has read and agree to the above and foregoing, and received a copy thereof, and is the duly authorized to enter this FFS agreement.

8. This agreement remains in place for 1 month (30 days) following the payment date. After that you have the right to choose another practice or Physician or continue our membership which is billed monthly at a current cost of $129.00 per month. This fee is subject to change according to the practice.  You will be informed of any changes made to the practice.  You can also be easily updated on www.misrawellness.com.

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim in the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select on arbitrator (party arbitrator) within thirty days and the third arbitrator (neutral arbitrator) should be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or the other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of California law applicable to health care providers shall apply to disputes with this arbitration agreement, including, but not limited to, Code of Civil Procedure Section 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgement or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05 however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions rating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect: If the patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) the patient should initial below.

Note:  Effective as of the date of first medical or aesthetic service.                       

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

With my consent, Misra Wellness™, Sulagna Misra, MD and associates, may use and disclose Protected Health Information (PHI) about me to carry out Treatment, Payment and Healthcare Operations (TPO).  Please refer to Misra Wellness's ™ Notice of Privacy Practices for a more complete description of such uses and disclosures. 

 I have had the opportunity to review the Notice of Privacy Practices prior to signing this consent.  Misra Wellness™ reserves the right to revise its Notice of Privacy Practices at any time.  A revised Notice of Privacy Practices may be obtained by forwarding a written request to Sulagna Misra, MD 18740 Ventura Blvd. Suite 204, Los Angeles, CA 91356.

 With my consent Misra Wellness™ may call my home or other designated location  and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out the Treatment, Payment and Healthcare Operations (TPO), such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, Misra Wellness™ may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

With my consent, Misra Wellness™ may email to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.  I have the right to request that Misra Wellness™ restrict how it uses or discloses my PHI to carry out TPO. 

However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. 

 By signing this form, I am consenting to Misra Wellness’s™ use and disclosure of myProtected Health Information (PHI) to carry out Treatment, Payment and Healthcare Operations (TPO.)

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.  If I do not sign this consent, Misra Wellness™ may decline to provide treatment to me.

Thank you for choosing Misra Wellness Men's Health DPC (Direct Primary Care)  as a part of your healthcare needs.  After payment, you will receive an email or phone call verifying payment was processed to schedule your appointment  This is the following process:

-After confirmation, your information may be submitted to Quest (or Labcorp) to draw bloodwork (will be submitted for all Men's Health Memberships as labs are needed to optimize hormones). Should you prefer to use your insurance for this option, please inform Dr. Misra immediately. Once submitted, it is recommended you schedule your bloodwork after a day of hydration and a good night’s rest.  Please try your best to avoid alcohol, fried or fatty foods, excessive sugar or carbohydrates and any form of THC as it may affect your lab results. Please also refrain from exercise 24 hours prior to all men's health and hormone related bloodwork.

-Once Quest has drawn blood, All fees are non-refundable. If you opt to use your health insurance for bloodwork, please inform the practice, thoug at times our negotiated prices are cheaper than those negotiated through Insurance.

-Get your labs drawn between the hours of 7:30am-9:00am. You MUST be fasting.  This step along with the timing is very important. Water only is permitted the morning of bloodwork.

-Once your lab results arrive, Dr. Misra or Aly will reach out to you through email or phone (or if opted in, through text) to schedule your appointment.  Appointments are best in to  perform a Comprehensive Physical Exam including prostate and testicular exam if needed. However, Misra Wellness understands you may have a busy schedule, so we also provide virtual appointments or with our Mobile Office (“Wellness Wheels”) where Dr. Misra comes to your location provided you have legal, oversized vehicle parking (this is a Concierge Service and has a fee starting at $350).  Any ticket received due to inappropriate parking will be billed immediately to the patient. 

-We also offer the programs completely virtually and Misra Wellness has achieved Legit Script Certification in order to provide this excellent service and meet all necessary medical standards.

-After your initial consultation, including review of labs and symptoms, if you medically qualify you will have the option for membership, currently priced at $249.00/month ($149/month for Men's Health and Medical Weight Loss).  This membership fee is charged monthly to ensure seamless followup and treatment and starts on one month from the the day of your first consultation with Dr. Misra.  

-Membership immediately starts if you are approved for the program. 

-Medications are not included with the initial consult or membership, but may be available at a discounted price.  If you would like treatment mailed to you, a shipping fee of $17.50-$165 will be added per shipment (the latter fee is to expedite medications from select compounding pharmacies or for large and irregular bulk orders done through Fed Ex or UPS).  For any controlled substances, an adult must be home to provide a signature to receive the package and you may be required to sign a controlled substances agreement. Weight Loss medications when shipped from pharmacies usually arrive ina temperature controlled manner and need to be refridgerated upon arrival. 

- Prices and fees are subject to change with or without notice to our patients.

-Currently we do not accept insurance, however insurance may cover the cost of your medication/ bloodwork/imaging. Should this change, you will be notified. For this reason we ask you to upload your insurance information.

-All fees must be paid when due to ensure a seamless experience and continuity of care to ensure you feel your best.

* We understand how busy life can be and do not generally charge for rescheduling, but recurrent rescheduling without prior notice (48 hours or 2 business days) will be subject to a $50 fee.

-Please reach out to admin@misrawellness.com to schedule appointments and follow ups with Nurse Aly. 

-Cancellations need to be requested in writing with 30 days notice to avoid additional charges. Restarting membership is $350 after termination and will require paperwork to be done again.

We look forward to serving you and getting you to your health and wellness goals!

By signing this form, I understand and agree with the following:

1.     Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants and other healthcare providers who are part of my clinical care team. In addition to myself and the members of my clinical care team, my family members, caregivers, or other legal representatives or guardians may join and participate on the telehealth/telemedicine service, and I agree to share my personal information with such family members, caregivers, legal representatives or guardians. The information may be used for diagnosis, therapy, follow-up and/or education. Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information, which may include:

• Progress reports, assessments, or other intervention-related documents

• Bio-physiological data transmitted electronically

• Videos, pictures, text messages, audio and any digital form of data

2.     The laws that protect the privacy and confidentiality of health and care information also apply to telehealth/telemedicine. Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except for the purposes of treatment, education, billing and healthcare operations. By agreeing to use the telehealth/telemedicine services, I am consenting to Misra Wellness  sharing of my protected health information with certain third parties as more fully described in the Misra Wellness Privacy Policy.

3.     I understand, agree, and expressly consent to Misra Wellness obtaining, using, storing, and disseminating to necessary third parties, information about me, including my image, as necessary to provide the telehealth/telemedicine services.

4.     As with any Internet-based communication, I understand that there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

5.     Individuals other than my clinical care team or consulting providers may also be present and have access to my information for the telehealth/telemedicine session. This is so they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies.

6.     Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinician(s), participant, patient or care team.

7.     I hereby release and hold harmless Misra Wellness and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.

8.     I understand and agree that the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record or information held at Misra Wellness.

9.     I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.

10.  I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time and revert back to traditional in-person clinic services. I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled.

All my questions have been answered to my satisfaction.

I hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and conditions.

By signing below, I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the above statements. I have had all my questions answered. I understand that this informed consent will become a part of my medical record.

I hereby give my consent for the use of compounded medications, including but not limited to semaglutide and tirzepatide, testosterone, anastrozole and other injectable, topical or oral medications as prescribed by my Physician at Misra Wellness. I understand that these medications are either not commercially available in this specific formulation or are made specifically for me and are being compounded by a licensed pharmacist.

I have been informed and understand the following:

1. **Purpose**: Semaglutide and tirzepatide are medications used to help manage
blood sugar levels in patients with type 2 diabetes and/or obesity. Testosterone +/-
Anastrozole and/or clomiphene citrate is used for hypogonadal hypogonadism and/or
hyper-estrogenism.

2. **Formulation**: The compounded medications will be prepared according to the
specifications provided by my Physician at Misra Wellness and may include additional
ingredients to ensure stability and effectiveness.

3. **Dosage and Administration**: I have been informed of the prescribed dosage and administration schedule for the compounded medications. I understand the importance of following these instructions carefully.

4. **Potential Risks and Side Effects**: I am aware of the potential risks and side effects associated with semaglutide and tirzepatide, testosterone, anastrozole or other compounded medications, including but not limited to:

- Injection site reactions
- Nausea
- Vomiting
- Constipation- Diarrhea
- Dehydration
- Fatigue
- Decreased appetite
- Abdominal Pain
- Acid Reflux
- Allergic reactions
- Very rarely hospitalization and/or death

5. **Monitoring and Follow-Up**: I understand the importance of regular monitoring with my Physician at Misra Wellness and other relevant parameters as determined by
Physician at Misra Wellness . I agree to attend follow-up appointments as scheduled.

6. **Alternative Treatments**: I acknowledge that alternative treatments may exist formanaging my condition and have been discussed with me. I understand that I have theright to refuse treatment or seek a second opinion.

7. **Confidentiality**: I understand that my medical information will be handled in
accordance with applicable privacy laws and regulations.

8. **Emergency Situations**: In the event of an emergency related to the use of the
compounded medications, I authorize my Physician at Misra Wellness to take
appropriate action to ensure my safety and well-being.

9. **Acknowledgment of Consent**: By signing this form, I acknowledge that I have read and understood the information provided above, and I consent to the use of
compounded medications as described.

I understand that I have a medical condition that requires use of controlled substance medication(s) because this medical condition has not been adequately controlled with non-controlled medications and that my functionality can be limited. I understand that the intent of this medication is to increase my ability to do more, though the controlled substance medication is unlikely to eliminate my condition altogether.

This agreement is between the aforementioned patient named above and Misra Wellness, specifically Dr. Sulagna Misra.

I will take the medication only as prescribed. I will not take any sedatives, cannabis, alcohol, recreational drugs or other controlled substance medications without the prior approval and discussion with my physician as these can interfere with the prescribed medications and result in a trip to the Emergency Room or death.

I understand that the medication will be prescribed only by Dr. Sulagna Misra and only according to the agreed upon schedule. Prescriptions will be provided only during regular business hours. Medications will not be called in to the pharmacy. 

I will not seek or accept any additional controlled substance medications (i.e. testosterone, pain, anxiety and/or stimulants) other than those prescribed by Dr. Sulagna Misra unless discussed specifically with Dr. Misra. This includes prescriptions from other doctors, medications borrowed or accepted from family or friends and any illicit or street/recreational drugs.

Medication refills will be provided as written prescriptions only. No refills will be given prior to 30 days unless otherwise discussed specifically with Dr. Sulagna Misra. I understand that I must make appointments with my doctor at least every (1) months or every (3) months or sooner (as directed by Dr. Misra) if my doctor recommends. No refills will be given if I do not keep these appointments. Two (2) no show appointments will constitute grounds for immediate dismissal from the practice.

I understand that my doctor is under no obligation to provide these medications to me, and that he/she reserves the right to discontinue or decrease these medications at any time. Dr. Misra also has the right to suggest alternative treatments to use in conjunction with or as a substitute to the medications prescribed by her.  If I refuse, I understand the medications will be stopped.

I understand that lost or stolen medications will not be refilled under any circumstances. It is my responsibility to protect and secure my medications. This includes keeping the medication out of reach of children. A copy of a police report will be required for any lost or stolen controlled substance prescriptions and must be provided to Dr. Misra and Misra Wellness as soon as the report is filed.

I understand that my doctor may request specialist evaluation of my treatment and I agree to keep appointments. My doctor will send a copy of my medical record and care to the referred physician.

I understand that at any time I may be required to bring my pills in for counting and may be required to take a drug test (which is financially covered by the patient) without prior notification.  Refusal to do either will result in immediate dismissal from the practice.

I understand crossing state lines to acquire controlled substances will result in dismissal from the practice.

I understand that suspicion and/or evidence of selling my medications for any value results in both dismissal from the practice as well as filing a police report.  

I understand that my doctor by law is required to report all controlled substances dispensed to me to the state monitored prescription monitoring program (CURES or other prescription monitoring program governed by State law)

 *In addition to the above agreements, I accept the right of my doctor’s staff to terminate this agreement for any of the following reasons:

I seek or obtain any pain medication from a source other than my doctor.
I in any way attempt to forge or alter a prescription
I distribute my prescribed medication(s) to any other person.
My medical condition declines to the point at which, in the judgment of my doctor, continued therapy with this medication presents danger to my well-being or safety.
There is evidence that I am no longer receiving a reasonable therapeutic benefit from the medication, or my doctor determines that I am no longer a good candidate to continue the medication.
At every office visit urine may be collected. Refusal of collection is grounds for immediate termination from Misra Wellness.

I agree to fill my prescriptions only at the pharmacy listed below. If I change pharmacies, I will contact my doctor’s office with the name, address and phone number of the new pharmacy. Under no circumstances will I obtain medications from more than one pharmacy at a time.

I understand that by signing this agreement, I must abide by the rules reviewed above and that failure to abide by these agreements will result in termination of medication prescriptions and immediate dismissal from Dr. Sulagna Misra and the practice.

I understand that if I default from this agreement and/or I am having a medical emergency I should call 911 or go to the nearest emergency room.