Consent Forms

I understand that my healthcare provider will provide telehealth-based medical services using interactive audio, video, and electronic communications. I understand that telehealth involves the communication of my medical information, both orally and visually. I understand that I have the right to withhold or withdraw consent at any time without affecting my right to future care. I understand that there are risks to telehealth, including but not limited to: information transmitted may not be sufficient to allow for appropriate medical decision making; delays in evaluation and treatment could occur due to failures of electronic equipment; security protocols could fail, causing a breach of privacy; and a lack of access to all medical records could result in adverse drug interactions or allergic reactions. I agree that my provider may determine that telehealth services are not appropriate for my condition and may require an in-person visit.

I consent to the medical evaluation and, if clinically appropriate, the prescribing of GLP-1 receptor agonist medication (such as semaglutide or tirzepatide) for weight management. I understand that these medications are prescription medications with potential side effects including but not limited to: nausea, vomiting, diarrhea, constipation, abdominal pain, headache, and in rare cases, pancreatitis, gallbladder problems, kidney problems, and thyroid tumors. I understand that results vary and weight loss is not guaranteed. I agree to follow my provider's instructions regarding dosing, monitoring, and follow-up. I will report any adverse effects promptly to my provider.

I consent to receive communications from EdenRx via email, SMS/text message, and through the secure messaging platform regarding my care, treatment updates, appointment reminders, and billing. I understand that non-sensitive notifications may be sent via email or SMS, but that protected health information will only be communicated through the secure patient portal. I may opt out of non-essential communications at any time.

I understand and agree that I am financially responsible for all charges associated with my treatment plan, including but not limited to: consultation fees, medication costs, shipping fees, and any applicable taxes. I authorize EdenRx and its payment processor to charge my payment method on file for recurring subscription payments according to my selected billing cycle. I understand that I may cancel my subscription at any time, with cancellation effective at the end of the current billing period. I understand that refunds are subject to EdenRx's refund policy.

I acknowledge that I have read, understand, and agree to EdenRx's Privacy Policy. I understand how my personal information and health data will be collected, used, and protected.

I acknowledge that I have received and reviewed EdenRx's HIPAA Notice of Privacy Practices. I understand my rights regarding my protected health information and how it may be used and disclosed.