ACKNOWLEDGEMENT AND UNDERSTANDING OF CARE

I understand that I am being evaluated for the potential use of peptide therapy, non-traditional medical therapy, and/or medical marijuana to treat my qualifying medical condition(s) under applicable state law. Peptide therapy may be used for performance enhancement, weight loss, and other purposes. Medical marijuana may be used for relief of symptoms related to chronic pain, PTSD, and other conditions approved by the state.
• I understand that peptide therapy and marijuana is not approved by the FDA and cannabis is still classified as a Schedule I drug under federal law.
• The use of medical marijuana is permitted only under state law and may not protect me from federal prosecution.

RISKS AND SIDE EFFECTS

I understand that potential side effects of peptide therapy use may include:

• Water retention / bloating

• Numbness or tingling in hands/feet (carpal‑tunnel–like symptoms)

• Headaches

• Joint pain or stiffness

• Fatigue or lethargy (varies by peptide)

• Insulin resistance / elevated blood sugar (especially MK‑677 and some GH secretagogues)

• Changes in lipid levels

• Increased appetite (noted with certain GH‑stimulating peptides)

• Gynecomastia (rare)

• Fluid shifts affecting blood pressure

• Potential hormone imbalance if dosing is excessive or unmonitored

• Redness or irritation

• Swelling or localized inflammation

• Risk of infection or abscess (especially with non‑medical‑grade products)

• Hypersensitivity reactions (rare but possible)

• Reactions to impurities in poorly regulated or non‑pharmacy peptides

• Contamination or incorrect dosing

• Unknown purity or potency

• Adverse reactions from impurities

I understand that potential side effects of marijuana use may include:
• Drowsiness, dizziness, fatigue
• Dry mouth, increased appetite
• Impaired short-term memory
• Anxiety, paranoia, or hallucinations
• Impaired motor skills and coordination
• Potential for dependence or addiction
I understand that using marijuana may impair my ability to drive or operate machinery and I should not engage in such activities while under its influence.

ALTERNATIVE TREATMENTS
I have been informed of other treatment options and have chosen to explore peptide therapy and/or medical marijuana use.

RESPONSIBILITIES
I agree to the following:
• I will not share, sell, or distribute prescriptions prescribed to me.
• I will use prescribed medications only as prescribed and directed.
• I will notify my provider of any side effects or changes in my condition.
• I will keep all prescribed medications secured and out of the reach of children.

• I will understand that I am NOT eligible for participation with this clinic and/or therapy if I am at any time covered by Medicare/Medicaid. 

NO GUARANTEE
I understand that there is no guarantee that prescribed therapy will improve my condition or symptoms.

FOLLOW-UP AND MONITORING
I agree to follow up with my provider as required to evaluate the effectiveness and safety of prescribed medications. 

CONSENT
By signing below, I acknowledge that:
• I have had the opportunity to ask questions.
• I understand the risks, benefits, and alternatives.
• I give my voluntary and informed consent to care under the care of my healthcare provider.

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TELEMEDICINE NOTICE 

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.

I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment. I may revoke my right at any time by contacting the office at 210-621-0717.
I understand that the laws that protect privacy as described above and the confidentiality of health care information apply to telemedicine services.

I understand that my health care information may be stored and shared securely across multiple healthcare interface platforms.

I understand fees are due at the time of service.

By clicking "I Agree" below, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).

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HIPAA NOTICE 

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. By providing your phone number and email, you consent to our team sending you updates, notices, and information via text, call, or email. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. By selecting "I Agree" below you agree to this notice and its practice and agree to have your medical information documented in a secure location.

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