Consent to Treat, Peptide Therapy, and Financial Agreement
Mavroson Medical, P.C. / Dr. SkinnyShot
Section 1 - General Consent to Treatment
I voluntarily consent to evaluation, diagnosis, and treatment by the providers of Mavroson Medical, P.C., d/b/a Dr. SkinnyShot and ReNu Medical ("the Practice"). This may include examinations, lab testing, diagnostic procedures, medications, and other treatments my provider deems appropriate.
I understand:
- All medical treatment carries potential risks and benefits. My provider will explain the nature, purpose, risks, and alternatives of any recommended treatment before I receive it.
- I may withdraw consent for treatment at any time by notifying the Practice in writing. Withdrawing consent does not affect care already provided.
- My health information is confidential and protected under HIPAA. It is shared only with those directly involved in my care, as required by law, or as I separately authorize.
- I am financially responsible for services rendered (see Section 5).
Section 2 - Privacy, Affiliate Care Coordination, and Telehealth Consent
Use and disclosure of health information. My protected health information (PHI) may be shared with providers and staff directly involved in my care, with my insurer to process claims, and as otherwise required by law. The Practice will retain my record for as long as I am a patient and for seven years after my last visit. I may request an accounting of disclosures or a copy of my record at any time.
Communication. With my consent, Dr. Mavroson or Practice staff may contact me by phone, mail, or email regarding appointment reminders, lab results, insurance items, and statements, marked confidential where applicable.
Telehealth. I understand that:
- The same privacy protections that apply to in-person care apply to telemedicine.
- I may withhold or withdraw consent to telemedicine at any time without affecting my right to future care.
- I may inspect or request copies of information recorded during a telemedicine visit.
- Telemedicine may involve transmitting my medical information to practitioners in other locations, including out of state.
- No specific outcome is guaranteed through telemedicine.
- I must be physically located in a state where my provider is licensed at the time of any direct-access telemedicine visit, must not be using controlled substances, and will be referred to an in-person clinic visit if my provider determines telemedicine is not appropriate for my condition. I will not receive direct-access telemedicine services while in crisis.
I have read and understand this section, have had the opportunity to ask questions, and give my informed consent to telemedicine as part of my care.
Section 3 - Consent to Non-Secure Electronic Communication
I understand that text messages, standard phone calls, and unencrypted email are not HIPAA-secure communication channels and may be intercepted or accessed by unauthorized parties. I consent to the Practice using these methods for appointment reminders, general health questions, follow-up instructions, and billing matters only - never for emergencies or time-sensitive issues.
I understand I am responsible for the security of my own devices, that I may request all communication occur through secure HIPAA-compliant channels instead, and that I may revoke this consent at any time in writing (revocation does not apply to messages already sent).
Section 4 - Informed Consent for Weight Loss and Peptide Therapy
This section covers compounded and prescription medications used in weight management, metabolic, hormonal, and wellness therapy, including but not limited to: Semaglutide, Tirzepatide, Retatrutide, Naltrexone, Vitamin B12, B6, Glycine, Tesamorelin, CJC-1295, Ipamorelin, BPC-157, PT-141, Kisspeptin, AOD-9604, Thymosin Alpha-1, TB-500, MOTS-C, and any other current or future compounded peptide or peptide-adjacent medication prescribed to me as part of this treatment plan, whether or not specifically named above.
Regulatory status disclosure. I understand and acknowledge that:
- Most peptides used in this practice are not FDA-approved for any indication, or are approved for a different indication than the one for which I am being treated (off-label use).
- Peptides prepared by a compounding pharmacy are not independently reviewed or approved by the FDA for safety, effectiveness, purity, sterility, or consistency between batches.
- Some peptides are research compounds with limited or no long-term human clinical trial data. Long-term effects, drug interactions, and rare risks may not yet be fully known or documented in medical literature.
- My provider will explain what is and is not currently known about each specific peptide recommended to me, based on available clinical and research literature, and I may ask questions about any medication before agreeing to treatment.
- My provider may prescribe from a compounding pharmacy of their choosing, and I authorize this.
Nature of treatment. These medications may be compounded and/or prescribed off-label. My provider has explained the rationale for each medication I receive, and I consent based on their clinical judgment and my own informed decision.
Potential benefits (not guaranteed) may include weight loss, improved metabolic or blood sugar regulation, increased energy, improved body composition, enhanced libido or sexual function, hormonal support, improved sleep or mood, accelerated healing or tissue repair, and reduced inflammation.
Potential risks may include: nausea, vomiting, diarrhea, constipation, abdominal discomfort or bloating; injection site reactions including redness, irritation, or infection; allergic reactions including rare anaphylaxis; headache, dizziness, or fatigue; mood, anxiety, or sleep changes; changes in blood pressure, heart rate, or blood sugar (including rare hypoglycemia); gallbladder issues or pancreatitis (rare); thyroid changes, including nodules; fluid retention or electrolyte shifts; changes in appetite; menstrual, libido, or fertility changes; and, for compounded medications specifically, variability in strength, purity, or effect due to the compounding process, as well as risks that are unknown, unanticipated, or not yet identified in current medical literature given the limited long-term data available for some of these compounds.
Contraindications - I confirm none of the following apply to me unless I have disclosed them to my provider: personal or family history of medullary thyroid carcinoma or MEN2, uncontrolled thyroid disease, active gallbladder disease, gastroparesis or severe GI disease, history of pancreatitis, pregnancy or breastfeeding (or plans for pregnancy), active untreated cancer, severe cardiovascular disease, or severe psychiatric disorders.
My responsibilities. I agree to disclose my full medical history, medications, supplements, and allergies; follow dosing instructions exactly as prescribed; attend recommended baseline and follow-up labs (every 3-6 months or as directed); notify my provider immediately of adverse reactions, side effects, or changes in health; not share my medication with others; obtain peptides only through the Practice's designated prescribing and pharmacy process; and understand that stopping therapy may result in loss of benefit or return of symptoms.
Alternatives. I have been informed of alternatives including FDA-approved weight-loss or hormone therapies, diet and lifestyle changes, behavioral therapy, physical therapy, and traditional medical treatment, and I may decline this therapy in favor of those options.
No guarantee. No specific result, degree of benefit, or absence of side effects, known or unknown, is guaranteed.
Release. I release Mavroson Medical, P.C., d/b/a Dr. SkinnyShot / ReNu Medical, its providers, and staff from liability related to these medications and therapies, including risks not yet known or documented due to the limited long-term data available for some compounds, except in cases of gross negligence or malpractice.
Section 5 - Financial Responsibility, Payment, and Refund Policy
Payment and insurance. I am financially responsible for any services not covered by insurance, including deductibles, copays, coinsurance, and any services my plan deems non-covered or out-of-network. Certain services - including many telemedicine visits, medications, and specific procedures - may not be covered by insurance at all, and I am responsible for those in full. Payment for consultation fees, copays, or non-covered services is due at the time of my appointment, or in advance for telemedicine visits, unless other arrangements have been made.
Outstanding balances. I agree to pay outstanding balances in a timely manner and may contact the billing department to arrange a payment plan. Unresolved balances may be sent to collections.
Fees. A $25 fee applies to returned checks or insufficient funds. Appointments require 24 hours' notice to cancel or reschedule; a $25 no-show/late-cancellation fee applies otherwise. This fee is not billable to insurance.
Medication orders are final. Professional medical services (consultations, evaluations, treatment planning, follow-up care) are earned at the time rendered and are non-refundable. Prescription medications, including compounded medications, are prepared by licensed pharmacies and may not be returned, exchanged, or refunded once prescribed, processed, compounded, dispensed, or shipped - regardless of whether the medication was opened or used. The Practice does not control pharmacy preparation timelines or shipping carrier delays, and these do not qualify for cancellation or refund. I am responsible for providing accurate shipping and contact information. If a shipment arrives damaged, defective, or incorrect, I must notify the Practice within 48 hours of delivery.
Chargebacks. Initiating a credit card chargeback or payment dispute after services have been rendered or medication ordered/shipped is a violation of this agreement, and the Practice may pursue recovery of the balance owed, including reasonable administrative or legal fees, to the extent permitted by law.
Updates. I agree to promptly inform the Practice of any change in insurance or contact information; failure to do so may result in claim denials or an inability to reach me for billing.
Section 6 - Concierge Membership Terms
I understand that Mavroson Medical, P.C. / Dr. SkinnyShot offers an optional concierge membership program, billed either monthly or annually (paid in advance), providing access to priority scheduling, extended visits, direct provider access. Membership fees are separate from, and in addition to, any charges for medications, labs, procedures, or other services rendered, unless otherwise stated in my membership plan.
Monthly membership.
- If I cancel within 2 calendar days of a monthly payment, that payment is refunded in full.
- After that 2-day window, I must provide the Practice 30 days' written notice to cancel. My membership remains active and billable through the end of the notice period. No refund is issued for the then-current billing period once the 2-day window has passed.
Annual membership (paid in advance).
- If I cancel within 2 calendar days of my annual payment, the full amount is refunded.
- After that 2-day window, I must provide the Practice 30 days' written notice to cancel prior to the annual renewal date. My membership remains active through the end of the notice period.
- Upon cancellation after the 2-day window, I will receive a refund of the unused, remaining full months of my membership term, calculated at the standard monthly membership rate, less [any applicable early-termination/administrative fee - amount to be set by Practice]. The month(s) covered by my 30-day notice period are considered used and are non-refundable.
General terms.
- Membership automatically renews at the end of each billing term (monthly or annual) unless I cancel in accordance with the notice requirements above.
- The Practice may modify membership pricing or included benefits with reasonable advance notice; continued membership after such notice constitutes acceptance of the updated terms.
- Membership guarantees access to concierge-level services as described in my plan but does not guarantee the availability of a specific provider at all times, nor any specific medical outcome.
- Cancellation of my concierge membership does not cancel any separate, ongoing treatment consents (e.g., Section 4) or outstanding financial obligations under Section 5, which remain governed by their own terms.
- Written notice of cancellation may be submitted by email or through the Practice's patient portal, and is effective as of the date received by the Practice.
Signature
By signing below, I confirm that I have read and understand each section above, have had the opportunity to ask questions, and give my informed consent to treatment by Mavroson Medical, P.C. / Dr. SkinnyShot.