RX Wellness LLC Informed Consent

EFFECTIVE DATE: June 9, 2026

Informed Consent for Telemedicine Services

Introduction

Telemedicine involves the use of electronic communications to enable health care providers to share individual patient medical information, for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. The primary difference between telemedicine and direct in-person service delivery is the inability to have direct, physical contact. The patient encounter is done via a platform that allows the patient and the physician to be in different physical locations.

Expected Benefits

• Improved access to medical care by enabling a patient to remain in his/her remote site while the physician can obtain medical test results and consults to enable greater coverage of care.
• More efficient medical evaluation and management.
• Obtaining expertise of a distant physician.

Possible Risks

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

Tips for a Successful Telemedicine Video Visit

• Check your internet connection
• Make sure your audio and video are working
• Find a quiet, private location if possible
• Check your lighting
• Write down problems and questions ahead of time
• Dress appropriately for the visit
• Consider using headphones
• Consider using a computer instead of your smart phone
• Have easy access on your computer to any pictures or medical reports you want to share with the medical provider
• Have your other medical devices ready to go
• Be an active participant in the exam
• Have a trusted assistant if necessary

Scheduling your Telemedicine Appointment

• An RX Wellness Health Associate will contact you with an available appointment date and time
• Payment is due at the time of scheduling
• An email will be sent with the providers room link for access to your telemedicine appointment

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GLP-1 + Peptide Therapy Informed Consent & Patient Agreement

Purpose of Treatment

This consent authorizes participation in a provider-directed weight loss and wellness program that may include GLP-1 medications (such as tirzepatide or semaglutide) and/or peptide therapies as part of an individualized treatment plan. The licensed healthcare provider maintains sole authority over evaluation, diagnosis, treatment selection, dosing, monitoring, and follow-up care.

Regulatory Status Acknowledgment

The Patient understands that:

• GLP-1 medications prescribed may be FDA-approved for certain indications but used off-label.
• Some peptide therapies are not FDA-approved medications and may be considered investigational or compounded preparations.
• Compounded medications are not reviewed by the FDA for safety, efficacy, or quality, and variability in formulation or potency may occur.

Potential Benefits

Potential benefits may include support for:

• Weight management and appetite regulation
• Metabolic health
• Energy levels
• Recovery and tissue health
• Overall wellness

Individual results vary and cannot be guaranteed.

Risks and Potential Side Effects

GLP-1 Therapy Risks

May include:

• Nausea, vomiting, diarrhea, constipation
• Decreased appetite
• Gallbladder disease
• Pancreatitis (rare)
• Blood sugar changes
• Possible thyroid tumor risk (as noted in animal studies)

Peptide Therapy Risks

May include:

• Injection site reactions, infection, or irritation
• Allergic reactions
• Fluid retention or hormonal effects
• Blood pressure or metabolic changes
• Potential effects on cellular growth, tissue repair pathways, or blood vessel formation
• Unknown or limited long-term safety data

Patient Responsibilities

The Patient agrees to:

• Provide accurate and complete medical history
• Disclose all medications, supplements, and conditions
• Follow prescribed dosing instructions
• Complete recommended labs and follow-ups
• Report adverse effects promptly (within 24 hours if significant)

Medication and Treatment Monitoring

The Patient agrees to notify the Provider before starting new medications or supplements during treatment. Failure to disclose additional substances may increase risk of adverse effects or interactions.

Administration, Storage, and Handling

If medications are self-administered, the Patient agrees to:

• Follow proper injection technique
• Use sterile practices
• Store medications appropriately (including refrigeration if required)
• Dispose of sharps safely

Improper administration may result in infection or injury.

Alternatives to Treatment

The Patient acknowledges that alternatives have been discussed, including:

• Lifestyle and dietary changes
• Exercise programs
• Traditional medical therapies
• No treatment

Telehealth and Medication Dispensing

The Patient understands that care may be provided via telehealth and medications may be shipped. The Patient assumes responsibility for proper receipt, storage, and use after delivery.

Financial Responsibility

These services are typically not covered by insurance. The Patient agrees to full financial responsibility for all services and medications. Refunds may not be available once medications are dispensed.

Privacy and HIPAA Compliance

Patient information will be handled in accordance with HIPAA regulations and may be shared with pharmacies, labs, or providers for care coordination.

I agree to participate in a telemedicine consultation for the procedure(s) described above by signing and dating on the webpage.