State of Texas - Telemedicine Informed Consent

Telemedicine uses secure videoconferencing (or, where appropriate, audio-only technology) to let a provider deliver care from a different location. By signing below, you consent to receive care from OneLife by telemedicine. Please read carefully and ask any questions before signing. I understand and agree that:

• Standard of care. The same standard of care applies as to an in-person visit; if telemedicine is not appropriate for my condition, I may be asked to be seen in person.
• Who is present. My provider and I will not be in the same room. I will be told of, and must consent to, anyone else present at either location.
• Benefits & limits. Telemedicine can improve access and convenience, but my provider cannot physically examine me and may not have all of my records.
• Technology risks. Risks include service interruptions, equipment failure, and interception despite reasonable safeguards. If the connection is inadequate, the visit may be stopped and continued another way.
• My right to stop. I may refuse or stop a visit at any time without affecting future care, and may revoke this consent by contacting OneLife at 210-239-5070.
• Privacy. HIPAA and Texas privacy laws apply. I have been offered the practice's Notice of Privacy Practices, which describes how my health information may be used and disclosed.
• Records & billing. This visit becomes part of my medical record and may be shared for care, scheduling, billing, and quality review. I am responsible for any copays or coinsurance, and telemedicine payment policies may differ from in-person visits.
• Location. I am physically located in Texas and will be in Texas during my telemedicine visit(s), and will confirm my location at each visit.

Attestation & Signature

I have read this form (or had it explained to me), my questions have been answered, and the risks, benefits, and alternatives have been explained in a language I understand.

Treatment Disclosure & Consent

Informed Consent for Compounded GLP-1 Medication

This consent describes a weight-management treatment plan that uses compounded semaglutide, tirzepatide, or retatrutide—a GLP-1 medication prepared by a licensed compounding pharmacy and NOT an FDA-approved finished product. FDA-approved brand-name versions (e.g., Ozempic/Wegovy for semaglutide; Mounjaro/Zepbound for tirzepatide) are the conventional alternatives. Please read carefully and ask any questions before signing. I understand and agree that:

Disclosures

• An appropriate medical history and physical examination have been completed, and conventional FDA-approved treatment options were discussed with me.
• Goals. The goals of treatment (weight loss and related metabolic improvement) and the expected outcomes and timeframe were explained.
• Risks & benefits. The risks and benefits of compounded GLP-1 therapy were explained, including common side effects (nausea, vomiting, diarrhea, constipation) and serious risks (e.g., pancreatitis, gallbladder disease, and the boxed warning for thyroid C-cell tumors).
• Not FDA-approved. I understand the compounded product is NOT FDA-approved, has not undergone FDA review for safety, efficacy, or manufacturing quality, and may differ from the brand-name product in strength, purity, or formulation.
• Differences. The differences between the compounded medication and the FDA-approved brand-name alternative were explained, including why compounding is being used and that the compounding pharmacy is licensed and follows applicable 503A/503B and state/federal standards.
• Treatment plan. A treatment plan tailored to my history, records, and exam was documented, including any need for further testing, monitoring, consults, or referrals, with review at reasonable intervals.
• My right to stop. I understand I may refuse or stop treatment at any time without affecting my right to future care, and may revoke this consent by contacting OneLife at 210-239-5070.