Thrive Integrative Health

CONSENT FOR TELEHEALTH CONSULT

1. I understand that I am voluntarily engaging in a telemedicine consultation with Thrive Integrative Health
2. I understand that the video conferencing technology and/or phone consultations will not be the same as a direct patient/health care provider visit due to the fact thatI will not be in the same room as my health care provider.
3. I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
6. I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with Thrive Integrative Health and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation.
7. I understand that telemedicine has limitations in regard tothe physical examination. I understand that the physical exam portion of the care provided through Thrive Integrative Health will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.
8. Telemedicine services offered through Thrive Integrative Health are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.
9. To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.
By signing this form, I certify:

• That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.
• That I have had the opportunity to ask questions and have had them answered to my satisfaction. 

*Please Note*
Tirzepatide/Semaglutide may decrease the efficacy of ORAL CONTRACEPTIVES

https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/215866s000lbl.pdf

https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/209637s003lbl.pdf

Vitamin B-12 helps maintain optimal health and has been shown to be beneficial in helping to reduce fatigue, improve memory, and maintain a healthy body weight. It is what your body uses to help create energy, which is one of the reasons people feel more energized when they take B12.

All medications and supplements have potential side effects, including B12. Most people tolerate B12 without issue, side effects are rare. Potential common B12 side effects include but are not limited to: mild diarrhea, upset stomach, nausea, pain at the injection site, swelling, headache and joint pain.

You acknowledge all of the following:

Tirzepatide is a compunded medication, not FDA approved.

That you will be initially started at a low dose and titrated gradually.

You understand that yo must report severe abdominal pain, vomitting, or dehydration and seek immediate medical attention if needed.

You understand that you should not share medication with others.

1. That if I begin to have side effects, I will contact Thrive Integrative Health immediately and notify them of what is happening.  

2. I understand that although rare, vitamin B12 injections can result in serious side effects. If these occur, you should follow up with a medical provider or go to the emergency department immediately. Uncommon and dangerous side effects include: rapid heartbeat, chest pain, flushed face, muscle cramps, weakness, difficulty breathing and swallowing, dizziness, confusion, rapid weight gain, feeling of tightness in the chest, hives and rashes, shortness of breath when there is no physical exertion and unusual wheezing and coughing.

3. Before starting vitamin B12 injections I agree to make my (LLC NAME/PROVIDER NAME) aware if I have any of these conditions: Leber’s Disease, liver disease, kidney disease, iron deficiency, folic acid deficiency, receiving any treatment or taking any medication that has an effect on bone marrow, or drug/supplement allergies.

4. I understand that there could be interactions with B12 and certain medications/supplements.

5. The use of B12 on a weekly to biweekly basis without a documented B12 deficiency is considered off label use and has not been FDA approved for increasing energy levels and weight loss.

5. Caution is advised while taking B12 if you have a sulfa allergy.

By signing below, I acknowledge that I have read the informed consent and agree to the treatment with its associated risks. I hereby give consent for B12 injections. I agree to inform my medical provider immediately if I have any side effects. I hereby release Thrive Integrative Health, and providers prescribing B12 and the person injecting the B12 of any damages or liability if anything was to occur. 

Indemnification Clause:

I agree to indemnify, defend, protect, and hold harmless the medical providers employed by THRIVE INTEGRATIVE HEALTH; and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical providers employed by THRIVE INTEGRATIVE HEALTH; rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed by THRIVE INTEGRATIVE HEALTH; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by THRIVE INTEGRATIVE HEALTH; I am aware of the potential side effects associated with hormone therapy, erectile dysfunction medications, and medications for weight management.  I accept all the risks involved in taking the medication(s) and will not seek indemnification or damages from the indemnified parties.

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

CDC Medication FACTS Sheet Tirzepatide/Semaglutide-Materials available on agency website free of charge, use of material does not imply endorsement.