Wellness Shop Order Form

I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as not being treated. Those risks and potential complications have been explained to me. I have not been promised or guaranteed any specific benefit from the administration of these therapies and no warranty or guarantee has been made regarding the results of treatment. I agree to proceed with treatment and to comply with recommended dosages. I agree to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of all aforementioned hormone levels or other diagnostic testing by a Coastal Wellness provider, my primary care physician, or other specialist. I agree to see my primary care physician, gynecologist, or other practitioner for regular monitoring and for preventative measures that may include but are not limited to complete physicals, rectal examinations and/or colonoscopy, EKG, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc. at least on a yearly basis. I agree to immediately report to my physician any adverse reaction or problem that might be related to my therapy. I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as to not being treated. Those risks and potential complications have been explained to me and I agree that I have received information regarding those risks, potential complications and benefits, and the nature of and other hormone treatments and have had all my questions answered. Furthermore, I have not been promised or guaranteed any specific benefit from the administration of hormone therapy. I certify this form has been fully explained to me, that I have read it or have had it read to me and that I understand its contents. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks and benefits. I agree to the therapy described above. I have been educated on the benefits, risks, and possible adverse reactions associated with hormone replacement therapy. I agree all the above health information submitted on the questionnaire is complete and accurate.

I understand that my Provider may or may not utilize telehealth and online communication services to conduct virtual examinations and manage my care plan. This may include 1) electronic consents and questionnaires delivered to my secure Patient Portal and required to be completed prior to my appointment 2) email communications regarding my appointment and login information, and 4) participating in my exam via two-way, live-streamed, video consultations for new and existing patients via a HIPAA-compliant portal.

Authorization to Evaluate Patient via Telehealth

I hereby consent to communicate by cell, e-mail, and online with my Provider so as to arrange and conduct virtual consultations, telemedicine/telehealth, and any other purposes deemed by my provider to be appropriate while I am receiving medical and aesthetic services.

As announced by the US Department of Health & Human Services (“HHS”) on March 17, 2020, I understand my Provider is now authorized to use non-public facing audio and/or video communication technology to provide telehealth, whether or not related to COVID-19, on an acceptable non-public facing platform. I accept that even authorized non-public facing third-party applications potentially introduce privacy risks, but my provider will enable all available encryption and privacy modes when using these applications.

Right to Withdraw Consent

I understand that I have the right to revoke this authorization in writing at any time, but if I do so it will have no effect on any actions taken prior to my revocation. Unless and until I revoke this authorization, it will exist in perpetuity from the date written below. I understand that I may refuse to sign this authorization and such refusal will have no effect on the medical treatment I receive from my Provider.

I release and discharge my Provider, the telehealth software portal and all parties acting under my Provider's license and authority from any telehealth medical privacy claims I might otherwise have had prior to HHS’s March 17, 2020 notification. I certify that I have read this Authorization and Release and fully understand its terms.

I have read the above Authorization & Release and consent to the use of Telehealth services.

HIPAA COMPLIANCE PATIENT CONSENT FORM

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

-Protected health information may be disclosed or used for treatment, payment, or  healthcare operations.
-The practice reserves the right to change the privacy policy as allowed by law.
-The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
-The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
-The practice may condition receipt of treatment upon execution of this consent.

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