Weight Loss Therapy Consent Form

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Privacy Policy

Effective Date: January 01,2026

Koreme Anti-Aging & Aesthetics Medical Group (“Koreme,” “we,” “us,” or “our”) is committed to protecting the privacy, confidentiality, and security of personal information and protected health information (“PHI”). This Privacy Policy explains how we collect, use, disclose, and safeguard information obtained through our website, telemedicine services, and related digital platforms.

1. Scope of This Policy

This Privacy Policy applies to:

Visitors to koremeantiaging.com
Patients who use our telemedicine, wellness, and anti-aging services
Individuals who communicate with us electronically or submit health information
This policy is intended to comply with applicable U.S. federal and state privacy laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

2. HIPAA Compliance and Protection of Health Information

Koreme Anti-Aging & Aesthetics Medical Group complies with HIPAA and all applicable federal and state laws governing the privacy and security of protected health information (PHI).

We maintain administrative, technical, and physical safeguards designed to protect the confidentiality, integrity, and availability of PHI, including but not limited to:

Secure data storage and encrypted communications
Role-based access controls limiting PHI access to authorized personnel only
HIPAA-compliant electronic systems and service providers
Policies and procedures designed to prevent unauthorized access, disclosure, or misuse of health information
Any third-party vendors or service providers who may have access to PHI on our behalf are contractually required to maintain HIPAA compliance.

3. Information We Collect

We may collect the following categories of information:

a. Personal Information

Name, email address, phone number
Billing and payment information
Account credentials
b. Health Information (PHI)

Medical history
Intake forms and questionnaires
Treatment-related data
Communications with healthcare professionals
c. Technical Information

IP address
Browser type
Device identifiers
Website usage data (via cookies or analytics tools)

4. How We Use Information

We use collected information to:

Provide medical, wellness, and telemedicine services
Communicate with patients regarding care, appointments, or services
Process payments and manage accounts
Improve our services and website functionality
Comply with legal, regulatory, and professional obligations
We do not sell, rent, or trade protected health information.

5. Disclosure of Information

We may disclose information:

To healthcare providers involved in your care
To HIPAA-compliant service providers assisting with operations
As required by law, regulation, or court order
To protect patient safety, public safety, or legal rights
All disclosures of PHI are limited to the minimum necessary as required by HIPAA.

6. Patient Rights Under HIPAA

Patients have the right to:

Request access to their health information
Request correction of inaccurate or incomplete information
Request restrictions on certain uses or disclosures
Request confidential communications
Receive an accounting of disclosures where required by law
Requests may be submitted using the contact information below.

7. Data Security

We employ industry-standard security measures designed to protect personal information and PHI from unauthorized access, alteration, disclosure, or destruction. While no system can be guaranteed 100% secure, we take reasonable and appropriate steps to safeguard all information under our control.

8. Cookies and Tracking Technologies

Our website may use cookies or similar technologies to enhance user experience and analyze website traffic. Users may control cookie preferences through their browser settings.

9. Jurisdiction and Applicability

This Privacy Policy applies to users and patients located in the United States and any other jurisdictions where Koreme Anti-Aging & Aesthetics Medical Group lawfully provides services. It is designed to comply with applicable privacy and data protection laws in those jurisdictions.

10. Changes to This Privacy Policy

We reserve the right to update this Privacy Policy at any time. Updates will be posted on this page with a revised effective date.

11. Contact Information

For questions, concerns, or requests related to privacy or protected health information, please contact:

Koreme Anti-Aging & Aesthetics Medical Group
📧 Email: info@koremeantiaging.com
🌐 Website: https://koremeantiaging.com
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HIPAA NOTICE OF PRIVACY PRACTICES

Effective Date: January 01, 2026

This Notice of Privacy Practices (“Notice”) describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.

Koreme Anti-Aging & Aesthetics Medical Group (“Koreme,” “we,” “us,” or “our”) is required by law to maintain the privacy of your protected health information (“PHI”) and to provide you with this Notice explaining our legal duties and privacy practices with respect to your PHI.

1. Our Legal Duties

We are required by law to:

Maintain the privacy and security of your PHI
Provide you with this Notice of our legal duties and privacy practices
Follow the terms of the Notice currently in effect
Notify you following a breach of unsecured PHI as required by law

2. Uses and Disclosures of Protected Health Information

We may use and disclose your PHI without your authorization for the following purposes:

a. Treatment

We may use and share your PHI to provide, coordinate, or manage your healthcare and related services. This includes communication with healthcare providers involved in your care.

b. Payment

We may use and disclose PHI to obtain payment for healthcare services provided to you, including billing, claims management, and payment processing.

c. Healthcare Operations

We may use and disclose PHI for operational purposes, such as quality assessment, staff training, licensing, accreditation, compliance, and business administration.

3. Other Permitted Uses and Disclosures

We may disclose PHI:

As required by federal, state, or local law
For public health and safety activities
To comply with legal proceedings or law enforcement requests
To prevent or reduce a serious threat to health or safety
To HIPAA-compliant service providers who support our operations under contractual confidentiality obligations

4. Uses and Disclosures Requiring Your Authorization

Any use or disclosure of PHI not described in this Notice will be made only with your written authorization. You may revoke an authorization at any time in writing, except to the extent action has already been taken in reliance on it.

5. Your Rights Regarding Your Health Information

You have the right to:

Access: Request to inspect or obtain a copy of your PHI
Amendment: Request corrections to your PHI
Accounting: Request a list of certain disclosures of your PHI
Restrictions: Request limits on how your PHI is used or disclosed
Confidential Communications: Request communications in a specific manner or location
Copy of This Notice: Obtain a paper or electronic copy of this Notice at any time
Requests must be submitted using the contact information below. We may deny certain requests as permitted by law.

6. Security of Your Information

We implement administrative, technical, and physical safeguards designed to protect your PHI from unauthorized access, use, or disclosure, in compliance with HIPAA and applicable laws.

7. Telemedicine and Electronic Communications

By using our telemedicine services, you acknowledge that communications may occur electronically. We utilize secure, HIPAA-compliant platforms and service providers to protect the privacy and security of your information.

8. Changes to This Notice

We reserve the right to change this Notice at any time. Changes will apply to all PHI we maintain. The updated Notice will be posted on our website and will include the revised effective date.

9. Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint.

10. Contact Information

For questions, requests, or complaints regarding this Notice or your protected health information, contact:

Koreme Anti-Aging & Aesthetics Medical Group
📧 Email: info@koremeantiaging.com
🌐 Website: https://koremeantiaging.com
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Referral Name* This field is required.
Dimitri Frangoulias
Gil Patino
Ray Rakhar, P.A.
Alessandra Almeida
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Full Name* This field is required.
First Name
Last Name
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Gender* This field is required.
Male
Female
Other
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Current Weight (in lbs)* This field is required.
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Target Weight (in lbs)* This field is required.
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Date of Birth* This field is required.
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Where Are You Located?* This field is required.
City
State
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Phone Number* This field is required.
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Email* This field is required.
example@example.com
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Weight Loss Therapy

GLP-1 receptor agonists such as Semaglutide, Tirzepatide, and Liraglutide are FDA-approved medications used to manage blood sugar and promote weight loss in eligible patients. This therapy is offered under medical supervision as part of a comprehensive wellness plan.

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Purpose of Treatment

GLP-1 medications are prescribed to reduce appetite, slow gastric emptying, enhance insulin sensitivity, and support long-term fat loss. They may also help regulate blood sugar in patients with insulin resistance or prediabetes.
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Kindly review the following and select any items that are applicable to your medical history or current health status.* This field is required.
I am at least 18 years old and not pregnant or planning to become pregnant.
I have no personal or family history of medullary thyroid carcinoma (MTC).
I have not been diagnosed with Multiple Endocrine Neoplasia syndrome type 2 (MEN2).
I do not have a history of pancreatitis or gallbladder disease.
I do not have gastroparesis or severe gastrointestinal motility issues.
I understand this medication may cause nausea, vomiting, or diarrhea, especially during the first few weeks.
I will inform my provider of any significant medical conditions or medication changes during treatment.
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I understand that a licensed medical provider will review my intake form and medical history to determine if this therapy is appropriate for me. No medication will be prescribed without clinical justification and professional medical judgment.
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Potential Risks and Side Effects

Common side effects include nausea, constipation, diarrhea, abdominal discomfort, headache, or fatigue. Serious but rare risks may include pancreatitis, kidney issues, allergic reactions, or gallbladder complications. The medication should be discontinued if you experience persistent severe abdominal pain, vision changes, or signs of dehydration.

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Monitoring and Follow-Up

I agree to participate in regular follow-up appointments as recommended by my provider. I understand that labs, vitals, and dosage adjustments may be required for safe and effective treatment.
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Please read and acknowledge the following disclosures to ensure informed consent and compliance with medical and legal standards.* This field is required.
I acknowledge that this treatment may include off-label or compounded formulations.
I consent to receive therapy via telehealth and understand that all evaluations and recommendations comply with state law.
I understand that Koreme Anti-aging & Aesthetics Group and its providers are not liable for adverse reactions due to undisclosed history, misuse, or noncompliance.
I understand that I may stop therapy at any time and that doing so will not affect my right to receive future care.
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Consent for Treatment

I have read and understand the above information. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I voluntarily consent to the use of GLP-1 therapy under medical supervision.
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Signature* This field is required.Please sign below to confirm that the information provided is accurate and that you have read and understood the above acknowledgments.
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