Virtual Care Appointment Form

Consent to Treat

Purpose of Consent

This form provides consent to evaluate, diagnose, and administer treatment to the patient named above. By signing below, the patient acknowledges and agrees to the terms described.

Consent to Treatment

General Consent
I voluntarily consent to the evaluation, diagnosis, and routine treatments provided by the healthcare providers at Mavroson Medical, P.C. I understand that such treatment may include examinations, lab testing, diagnostic procedures, medications, and other treatments deemed necessary by my provider.

Understanding of Treatment Risks
I acknowledge that all medical procedures and treatments involve potential risks and benefits. My provider will inform me of the nature and purpose of any recommended treatments, as well as potential side effects, risks, and alternative treatment options.

Right to Withdraw Consent
I understand that I have the right to withdraw my consent for treatment at any time by notifying the healthcare provider or staff in writing. Withdrawing consent will not affect any care already provided.

Confidentiality and Privacy
I understand that my health information will be kept confidential in accordance with HIPAA regulations. Information about my health will only be shared with individuals directly involved in my care or as required by law.

Financial Responsibility
I acknowledge that I am responsible for payment of any fees or charges associated with the services provided. I understand that I may contact the billing department at any time for questions regarding charges.

HIPPA/PHI Consent

1. HIPPA/PHI Consent

 PRIVACY POLICY (HIPPA) PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

Federal regulations require health practices to keep your medical information protected. Protected Health Information (PHI), is shared with affiliate healthcare practitioners, as well as healthcare providers that participate in your care, your insurance company to obtain payment for health benefits claims filed, or management of health issues relating to your health. All associates assisting with our internal operations are required to maintain confidentiality of protect health information. All other releases of information have to be specifically authorized by you. If you ask us to account for these release of information, we will provide that to you. You may also request and receive a copy of your medical record and ask questions about its content. We will keep your record as long as you are a patient of the practice and seven years after your last visit. You will be given a form to sign which shows the details of to whom you wish to have your PHI (Protected Health Information) released.

With my consent Matthew Mavroson, D.O., 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 TPO, such as appointment reminders, insurance items and any call pertaining laboratory results among others.

With my consent, Matthew Mavroson, D.O., 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, Matthew Mavroson, D.O., may e-mail to my home or or other designated location any items that assist the practice in carrying out their TPO, such as reminder cards and patient statements.

I acknowledge that I have been informed about the privacy of my medical record.

Telehealth Disclaimer:

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

I understand that I have the right to inspect all information obtained and recorder in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.

I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at this time. My provider has explained the alternatives to my satisfaction.

I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

I understand that it is my duty to inform my provider of electronic interactions regarding my care that i may have with other healthcare providers.

I understand that i may expect the anticipated benefits from the use of telemedicine in my care. But that no results can be guaranteed or assured.

I understand, acknowledge and agree that the following must be strictly complied with if I receive direct access telemedicine services:

I shall be physically present in the state the provider is licensed;

I do not use controlled substances.
I will be referred to the clinic for services if the provider determines I am unstable to receive direct access telemedicine services.

I will not receive direct access telemedicine services if I am in crisis.

Patient Consent To The Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

CONSENT FOR NON-HIPAA-COMPLIANT ELECTRONIC COMMUNICATIONPurpose of Consent

1. CONSENT FOR NON-HIPAA-COMPLIANT ELECTRONIC COMMUNICATION

Purpose of This Consent

By signing this form, you agree to communicate with ReNu Medical/Dr. Skinny Shot through non-HIPAA-compliant electronic means, including text messaging, standard cell phone calls, and/or unencrypted email. This form explains the risks involved and your rights regarding these communications.

Types of Non-Secure Communication

Text Messages: Short message service (SMS) or multimedia messaging service (MMS) to discuss appointment reminders, test results, general health questions, or follow-up instructions.
Cell Phone Calls: Communication for scheduling, medical instructions, or other non-urgent issues.
Unencrypted Email: Sending and receiving information related to appointments, general health information, or billing questions.

Risks of Non-Secure Communication

Privacy Risks: Non-HIPAA-compliant electronic communications are not secure. There is a risk that messages may be intercepted, read, or accessed by unauthorized parties.
Miscommunication: Due to the nature of electronic communication, messages could be misinterpreted or contain incomplete information.
Loss of Confidentiality: These methods lack the encryption required by HIPAA for protecting your personal health information.
Terms of Consent

Voluntary Participation
Your decision to communicate via these methods is voluntary. You may refuse or withdraw consent at any time by notifying our office in writing.
Appropriate Uses
Non-HIPAA-compliant electronic communication is intended for limited purposes, such as scheduling, general health questions, and appointment reminders. These methods should not be used for emergencies or time-sensitive health issues.

Right to Revoke
You have the right to revoke this consent at any time by notifying ReNu Medical in writing. Revocation does not apply to any communications sent before the effective date of revocation.
Responsibility
You are responsible for protecting the security of your own devices. ReNu Medical/Dr. Skinny Shot is not responsible for unauthorized access to messages once they are sent.
Alternative Methods
You may request that all communications occur through secure, HIPAA-compliant methods. Please contact us if you prefer this option.
Consent Acknowledgment

By signing below, you acknowledge that you understand the risks associated with non-HIPAA-compliant electronic communication and consent to the use of text messaging, phone calls, and/or unencrypted email for communication with ReNu Medical / Doctor Skinny Shot

Patient Consent Form for Weight Loss Medications and Enhancements

Purpose of Treatment

I, the undersigned, consent to receive treatment with compounded injectable, sublingual, and oral medications, as well as weight loss enhancement therapies prescribed to support weight loss, improve metabolic health, and enhance overall wellness. These treatments are part of a personalized weight management program tailored to my health needs.

 
Compounded Medications

Semaglutide
Semaglutide: A GLP-1 receptor agonist that regulates appetite and blood sugar to promote weight loss.

Tirzepatide
Tirzepatide: A dual GLP-1 and GIP receptor agonist that enhances weight loss and metabolic regulation.

Comounded Medications
Vitamin B12: Supports energy levels, red blood cell production, and neurological health.
Glycine: An amino acid that supports muscle health, improves sleep quality, and promotes overall wellness.

B6: Vitamin B6, also known as pyridoxine, is an essential water-soluble vitamin that plays crucial roles in various bodily functions. Supports metabolism and is crucial for breaking down protein, fats, and carbohydrates, which helps your body convert food into energy. 

B12:Vitamin B12: Supports energy levels, red blood cell production, and neurological health.

Glycine: An amino acid that supports muscle health, improves sleep quality, and promotes overall wellness.

Naltrexone
Purpose: Helps reduce cravings and improve control over eating behaviors.

Potential Benefits

I understand that the potential benefits of these medications and therapies include:

Significant weight loss when combined with a healthy diet and exercise.
Improved blood sugar regulation and metabolic health.
Enhanced energy levels and overall wellness.

Potential Risks and Side Effects

I acknowledge that there are potential risks and side effects, including but not limited to:

Semaglutide and Tirzepatide (Injectable, Sublingual, and Oral)

Gastrointestinal side effects such as nausea, vomiting, diarrhea, or constipation.
Abdominal discomfort, bloating, or rare risks like pancreatitis or gallbladder issues.
Potential hypoglycemia (low blood sugar), especially when combined with other medications.
Vitamin B12 and Glycine

Rare allergic reactions or mild discomfort at the injection site (Vitamin B12).
Potential mild gastrointestinal upset or rare allergic reactions (Glycine).
Naltrexone

Nausea, headache, dizziness, or fatigue.
Potential mood changes or sleep disturbances.
I understand that compounded medications are not FDA-approved as combinations but are prepared by a licensed compounding pharmacy based on my provider’s prescription.

 
Acknowledgment of Off-Label Use

I acknowledge that some uses of these medications may be considered off-label, meaning they are prescribed in a way not originally approved by the FDA. My provider has explained the rationale for this use and discussed the potential risks and benefits.

Patient Responsibilities

I agree to:

Follow all instructions provided by my healthcare provider regarding the use and administration of these medications.
Disclose my full medical history, including any allergies, current medications, or supplements.
Notify my provider immediately if I experience any adverse reactions, side effects, or concerns.
Attend follow-up appointments as recommended to monitor progress and adjust treatment if necessary.

Alternative Treatments

I have been informed about alternative treatment options, which may include:

Dietary and lifestyle modifications alone.
Other prescription weight-loss medications or programs.
Non-invasive weight loss therapies.
I understand that I may decline these medications and therapies and pursue other options.

Consent and Release

I understand that while these treatments are designed to improve my health and support weight loss, no results are guaranteed. I consent to proceed with treatment based on my healthcare provider’s clinical judgment and my own informed decision.

I release ReNu Medical / Doctor Skinny Shot, its healthcare providers, and staff from any liability related to the prescribed compounded medications and therapies, except in cases of gross negligence or malpractice.

FINANCIAL RESPONSIBILITY AGREEMENT

 

Financial Responsibility Agreement

Purpose of Agreement

This Financial Responsibility Agreement outlines your financial obligations for services received at [Practice Name]. By signing this document, you acknowledge your understanding and acceptance of the terms below.

Financial Responsibility Terms

Insurance and Payment of Services
I acknowledge that I am financially responsible for any services not covered by my insurance, including deductibles, copayments, coinsurance, and any services deemed non-covered or out-of-network by my insurance plan.

Non-Covered Services
I understand that certain services provided by ReNu Medical/Dr. Skinny Shot may not be covered by insurance and that I am responsible for payment of these services in full. Non-covered services may include certain telemedicine services, medication costs, and specific treatments or procedures outside my insurance plan’s coverage.

Payment Due at Time of Service
I agree to pay any consultation fees, copayments, deductibles, or fees for non-covered services at the time of my appointment unless other arrangements have been made in advance with ReNu Medical/Dr. Skinny Shot. For telemedicine visits, payment may be required prior to the scheduled visit.

Outstanding Balances and Payment Plans
If I have an outstanding balance, I agree to make timely payments as outlined by ReNu Medical / Doctor Skinny Shot. If necessary, I may contact the billing department to set up a payment plan. I understand that failure to pay outstanding balances may result in collection efforts or service limitations until the balance is resolved.

Returned Checks and Late Fees
I understand that a fee of $25 may be charged for returned checks or insufficient funds.

Appointment Cancellations and No-Show Fees
I agree to provide at least 24 hours notice if I need to cancel or reschedule an appointment. I understand that I may be charged a cancellation or no-show fee of $25 if sufficient notice is not provided. This fee is not billable to insurance and is my responsibility.

Authorization for Release of Information
I authorize ReNu Medical / Doctor Skinny Shot to release any necessary medical or billing information to my insurance company for processing claims or to third-party agencies for collections purposes, if required.

Changes in Insurance or Personal Information
I agree to inform ReNu Medical / Doctor Skinny Shot of any changes in my insurance coverage or personal information, including address, phone number, and email. Failure to update this information may result in claim denials or inability to reach me for billing purposes.

Payment, Refund, and Medication Dispensing Policy
By signing this agreement and proceeding with treatment, I acknowledge and agree to the following terms regarding medical services and prescription medications provided through this practice.

All medical consultations, evaluations, treatment planning, administrative services, and follow-up care constitute professional medical services. Fees for these services are earned at the time services are rendered and are non-refundable.

Prescription medications, including compounded medications, are prepared and dispensed by licensed pharmacies in accordance with federal and state pharmacy regulations. Due to these regulations and patient safety requirements, prescription medications may not be returned, exchanged, or refunded once they have been prescribed, processed, compounded, dispensed, or shipped, regardless of whether the medication has been opened or used.

I understand and agree that:

• All medication orders are final once submitted to the dispensing pharmacy.
• No refunds or returns are permitted for prescription medications under any circumstances once processing has begun.
• The medical practice does not manufacture or dispense medications directly and is not responsible for pharmacy preparation timelines.
• Shipping timelines and carrier delays are outside the control of the medical practice and do not qualify for cancellation or refund.
• I am responsible for providing accurate shipping and contact information at the time of order.

If a medication shipment arrives damaged, defective, or incorrect, I must notify the practice within 48 hours of delivery so the issue can be reviewed with the dispensing pharmacy.

I further acknowledge that initiating a credit card chargeback or payment dispute after services have been rendered or medication has been ordered or shipped constitutes a violation of this agreement, and the practice reserves the right to pursue recovery of the balance owed, including any associated administrative or legal fees to the extent permitted by law.

By signing this consent, I confirm that I have read, understand, and agree to this Payment, Refund, and Medication Dispensing Policy.

Acknowledgment of Financial Responsibility
I acknowledge that I have read and understand this Financial Responsibility Agreement and that I am responsible for paying all charges for services rendered by ReNu Medical/Dr. Skinny Shot, regardless of insurance coverage.
Agreement Acknowledgment

By signing below, I agree to the terms of this Financial Responsibility Agreement. I understand my financial responsibilities and agree to comply with the policies described above.

 

Patient Consent Form for Weight Loss Medications and Enhancements

Purpose of Treatment

I, the undersigned, consent to receive treatment with compounded injectable, sublingual, and oral medications, as well as weight loss enhancement therapies prescribed to support weight loss, improve metabolic health, and enhance overall wellness. These treatments are part of a personalized weight management program tailored to my health needs.

 
Compounded Medications

Semaglutide
Semaglutide: A GLP-1 receptor agonist that regulates appetite and blood sugar to promote weight loss.

Tirzepatide
Tirzepatide: A dual GLP-1 and GIP receptor agonist that enhances weight loss and metabolic regulation.

Comounded Medications
Vitamin B12: Supports energy levels, red blood cell production, and neurological health.
Glycine: An amino acid that supports muscle health, improves sleep quality, and promotes overall wellness.

B6: Vitamin B6, also known as pyridoxine, is an essential water-soluble vitamin that plays crucial roles in various bodily functions. Supports metabolism and is crucial for breaking down protein, fats, and carbohydrates, which helps your body convert food into energy. 

B12:Vitamin B12: Supports energy levels, red blood cell production, and neurological health.

Glycine: An amino acid that supports muscle health, improves sleep quality, and promotes overall wellness.

Naltrexone
Purpose: Helps reduce cravings and improve control over eating behaviors.

Potential Benefits

I understand that the potential benefits of these medications and therapies include:

Significant weight loss when combined with a healthy diet and exercise.
Improved blood sugar regulation and metabolic health.
Enhanced energy levels and overall wellness.

Potential Risks and Side Effects

I acknowledge that there are potential risks and side effects, including but not limited to:

Semaglutide and Tirzepatide (Injectable, Sublingual, and Oral)

Gastrointestinal side effects such as nausea, vomiting, diarrhea, or constipation.
Abdominal discomfort, bloating, or rare risks like pancreatitis or gallbladder issues.
Potential hypoglycemia (low blood sugar), especially when combined with other medications.
Vitamin B12 and Glycine

Rare allergic reactions or mild discomfort at the injection site (Vitamin B12).
Potential mild gastrointestinal upset or rare allergic reactions (Glycine).
Naltrexone

Nausea, headache, dizziness, or fatigue.
Potential mood changes or sleep disturbances.
I understand that compounded medications are not FDA-approved as combinations but are prepared by a licensed compounding pharmacy based on my provider’s prescription.

 
Acknowledgment of Off-Label Use

I acknowledge that some uses of these medications may be considered off-label, meaning they are prescribed in a way not originally approved by the FDA. My provider has explained the rationale for this use and discussed the potential risks and benefits.

Patient Responsibilities

I agree to:

Follow all instructions provided by my healthcare provider regarding the use and administration of these medications.
Disclose my full medical history, including any allergies, current medications, or supplements.
Notify my provider immediately if I experience any adverse reactions, side effects, or concerns.
Attend follow-up appointments as recommended to monitor progress and adjust treatment if necessary.

Alternative Treatments

I have been informed about alternative treatment options, which may include:

Dietary and lifestyle modifications alone.
Other prescription weight-loss medications or programs.
Non-invasive weight loss therapies.
I understand that I may decline these medications and therapies and pursue other options.

Consent and Release

I understand that while these treatments are designed to improve my health and support weight loss, no results are guaranteed. I consent to proceed with treatment based on my healthcare provider’s clinical judgment and my own informed decision.

I release ReNu Medical / Doctor Skinny Shot, its healthcare providers, and staff from any liability related to the prescribed compounded medications and therapies, except in cases of gross negligence or malpractice.

Patient Consent Form for Peptide Therapy

PURPOSE OF THIS CONSENT
This consent form outlines the potential risks, benefits, alternatives, and responsibilities associated with the use of peptide-based therapies. Peptides used in this practice may include, but are not limited to: Semaglutide, Tirzepatide, Tesamorelin, CJC-1295, Ipamorelin, BPC-157, PT-141, Kisspeptin, AOD-9604, Thymosin Alpha-1, TB-500, MOTS-C, and other compounded peptide medications. These medications may be prescribed for weight management, metabolic support, hormonal optimization, sexual health, healing, and wellness purposes.

Because many peptides are compounded, off-label, or not FDA-approved for the specific indication for which they are being used, this consent provides comprehensive protection for both physician and patient through clear disclosure.

NATURE OF PEPTIDE THERAPY
Peptides are short chains of amino acids that act as signaling molecules in the body. Although some peptides exist naturally in the human body, synthetic or compounded forms may not be FDA-approved or FDA-reviewed for safety, effectiveness, or sterility. Compounded medications are not evaluated or approved by the FDA and may carry additional risks.

You acknowledge and understand:

Peptide therapy is considered elective and may be off-label.
Benefits are not guaranteed and may vary from person to person.
Your treatment will be individualized based on your clinical history, goals, labs, and physician judgment.

POTENTIAL BENEFITS
Potential benefits of peptide therapy may include, but are not guaranteed:

Improved body composition and fat loss
Increased muscle mass or recovery
Enhanced libido or sexual function
Hormonal balance support
Improved skin, hair, or anti-aging effects
Enhanced sleep, mood, or cognitive clarity
Accelerated healing or reduced inflammation
You understand results differ between individuals and may be minimal or absent.

POTENTIAL RISKS & SIDE EFFECTS
Risks vary depending on the peptide used. Potential risks may include, but are not limited to:

General Risks
Nausea, vomiting, diarrhea, constipation
Flushing, dizziness, headaches
Injection site redness, irritation, or infection
Allergic reactions, including rash or anaphylaxis (rare)
Mood changes, anxiety, or sleep disturbances
Fatigue or changes in energy levels
Water retention or bloating
Changes in appetite
Elevated blood sugar or low blood sugar
Increased blood pressure or heart rate
Gallbladder issues (particularly with GLP‑1 based peptides)
Development or worsening of gastroparesis
Pancreatitis (rare but possible)
Thyroid changes, including nodules or enlargement
Risks Specific to Compounded Medications
Variability in strength, potency, or purity
Sterility issues
Medication contamination
Unexpected effects due to formulation variability
Hormonal or Metabolic Risks
Menstrual changes
Changes in libido
Fertility changes
Fluid shifts or electrolyte changes
You agree to report any concerning symptoms immediately.

CONTRAINDICATIONS
You confirm none of the following apply unless disclosed to the physician:

History of medullary thyroid carcinoma (personal or family)
Multiple endocrine neoplasia type 2 (MEN2)
Uncontrolled thyroid disease
Active gallbladder disease
Severe GI disorders (e.g., gastroparesis)
History of pancreatitis
Pregnancy or breastfeeding
Active cancer unless approved by oncology
Severe cardiovascular disease
Severe psychiatric disorders

TREATMENT EXPECTATIONS & RESPONSIBILITIES
By signing this form, you acknowledge and agree to the following:

You will disclose all medical history, medications, supplements, and allergies.
You will undergo initial and follow-up labs as recommended.
You will attend follow-up visits as required for medication continuation.
You will follow dosing instructions exactly as prescribed.
You will notify the physician of any adverse reactions or changes in health.
You will not share your medication with others.
You understand peptide therapy is not a substitute for diet, lifestyle, or medical management of chronic conditions.
You understand stopping therapy may result in loss of benefits or return of symptoms.

ALTERNATIVES TO PEPTIDE THERAPY
Alternative options include:

FDA-approved weight loss or hormone therapies
Diet and lifestyle interventions
Behavioral therapy
Physical therapy or exercise programs
Traditional medical treatments
You acknowledge these alternatives have been explained.

OFF-LABEL USE DISCLOSURE
Many peptide medications are used off-label, meaning they are not FDA-approved for the specific condition being treated. You consent to receiving these medications based on physician judgment.

NO GUARANTEE STATEMENT
You understand the physician cannot guarantee:

Specific results
Degree of benefit
Absence of side effects or complications

FINANCIAL RESPONSIBILITY
You acknowledge:

Peptide therapy may not be covered by insurance.
Fees for consultation, labs, and medication are your responsibility.
Refunds for compounded medications are not available once dispensed.

COMPOUNDING PHARMACY DISCLOSURE
Your medication may be produced by a compounding pharmacy. You understand:

Compounded medications are not FDA-approved.
The FDA does not verify their safety, effectiveness, or sterility.
Variations may occur in potency or effect.
You authorize the physician to prescribe from a pharmacy deemed appropriate.

TESTING & FOLLOW-UP REQUIREMENTS
You agree to:

Baseline labs before initiation unless deemed unnecessary by the physician
Periodic monitoring every 3–6 months
Additional labs based on clinical findings or risks
Follow-up appointments for medication refills
Failure to complete follow-ups may result in discontinuation of treatment.

PREGNANCY & FERTILITY DISCLAIMER
Certain peptides may:

Affect menstrual cycles
Influence fertility
Be unsafe during pregnancy or breastfeeding
You agree to notify the clinic immediately if you plan pregnancy or become pregnant.

Consent and Release

I understand that no treatment is guaranteed to be successful, and I consent to proceed with the prescribed medications based on my provider’s clinical judgment and my own informed decision.

I release ReNu Medical / Doctor Skinny Shot, its healthcare providers, and staff from any liability related to the prescribed compounded medications, except in cases of gross negligence or malpractice.

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