Mapo Wellness Center Evaluation/Order Form

I understand that, in addition to the benefits of any medical treatment or therapy, there are risks and potential consequences associated with treatment, as well as the possibility of not being treated. The risks and probable problems have been presented to me. I have not been promised or guaranteed any specific benefit from the administration of any therapies, and there is no warranty or guarantee about treatment outcomes. I agree to proceed with the treatment and follow the suggested dosages. I agree to comply with requests for continuous testing to ensure adequate monitoring of my treatments, which may include a laboratory review of the aforementioned hormone levels or other diagnostic tests by my primary care physician or another specialist. I promise to notify my doctor right away of any negative side effects or issues that may arise from my treatment. I am aware that, in addition to the advantages of any medical therapy or treatment, there are dangers and possible side effects associated with both receiving treatment and not receiving it. I acknowledge that I have received information about the dangers, potential effects, and benefits of hormone therapy, as well as the nature of other hormone treatments, and that I have had all of my questions addressed. Furthermore, no particular advantage from the use of hormone therapy has been assured or promised to me. 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 weight loss therapy. I agree all the above health information submitted on the questionnaire is complete and accurate.

In order to manage my care plan and do virtual exams, my provider may or may not use telehealth and online communication tools. This might include 1) electronic consent forms and surveys that are sent to my secure email and must be filled out before my treatment. 4) taking part in my exam through two-way, live-streamed, video consultations for both new and existing patients via a HIPAA-compliant gateway, and 2) receiving emails about my visit. Permission to Conduct Telehealth Patient Evaluations. In order to set up and carry out virtual consultations, telemedicine/telehealth, and any other purposes my physician deems suitable while I am receiving medical and aesthetic services, I thus consent to communicating with my provider via cell, email, and internet. I am aware that my provider is now permitted to use non-public facing audio and/or video communication technology to provide telehealth, whether or not it is related to COVID-19, on an acceptable non-public facing platform, as stated by the US Department of Health & Human Services ("HHS") on March 17, 2020. I understand that even approved third-party apps with a private interface could pose privacy issues, but my provider will turn on all encryption and privacy settings when I use these apps. The ability to revoke consent. I am aware that this authorization can be revoked in writing at any time, although doing so will not affect any activities that were made before then. This authority will be in effect indefinitely from the date indicated below, until and until I revoke it. I am aware that I have the option not to sign this permission, and that doing so will not impact the medical care 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.

Form for Patient Consent in HIPAA Compliance We discuss how we may use or disclose protected health information in our Notice of Privacy Practices. A section on patient rights in the notice outlines your legal rights. By completing this consent, you attest that you have read our notice and understand it. You will be informed during your subsequent visit to amend your signature and date if the notice's conditions change. You are entitled to limit the use and disclosure of your protected health information for purposes of treatment, payment, or healthcare operations. Although we are not obligated to accept this restriction, we will uphold it if we do. Information may be used for treatment, payment, or healthcare operations under the Health Insurance Portability and Accountability Act of 1996. You agree to our use and dissemination of your protected health information, including its possible anonymous use in a publication, by signing this form. This consent may be withdrawn at any time by you in writing and signed by you. Such a revocation won't be effective retroactively, though. By signing this document, I acknowledge that: -Healthcare operations, payment, or treatment may involve the disclosure or use of protected health information. 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.