Patient Forms

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get

access to this information. PLEASE REVIEW IT CAREFULLY.

OUR COMMITMENT TO YOUR PRIVACY
This Notice describes how we may use and disclose your Protected Health Information (PHI) to carry out reatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
Treatment: We may use your PHI to provide, coordinate, or manage your health care and related services, including sharing information with other providers involved in your care.
Health Care Operations: We may use and disclose your PHI for quality assessment, staff training, legal services, auditing, and other business activities necessary to operate our clinic.
Appointment Reminders: We may contact you by phone, text, or email to remind you of scheduled appointments.
Required by Law: We will disclose your PHI when required to do so by federal, state, or local law (e.g., mandatory reporting of certain communicable diseases, abuse, or neglect).
Public Health Activities: We may disclose PHI to public health agencies to prevent or control disease, injury, or disability.
Serious Threat to Health or Safety: We may disclose PHI if we believe in good faith that it is necessary to prevent or lessen a serious and imminent threat.
USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION
We will obtain your written authorization before using or disclosing your PHI for the following purposes: Marketing purposes, Sale of PHI and Most uses of psychotherapy notes. You may revoke an authorization in writing at any time, except to the extent we have already taken action based on it. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the right to:

• Request restrictions on certain uses and disclosures of your PHI.
• Receive confidential communications by alternative means or at alternative locations.
• Inspect and copy your PHI (a fee may apply).
• Request an amendment to your PHI.
• Receive an accounting of disclosures of your PHI.
• Receive a paper copy of this Notice upon request.
• File a complaint if you believe your privacy rights have been violated.

ACKNOWLEDGMENT OF RECEIPT
By signing below, you acknowledge that you have received, reviewed, and had an opportunity to ask questions about this Notice of Privacy Practices.

Weight Loss and Wellness Services

GENERAL CONSENT TO TREATMENT
I, the undersigned, voluntarily consent to medical evaluation, treatment, and procedures performed by the providers and staff of Precision Metabolic Health, I understand that:

1. No guarantee of specific results has been made.
2. I have the right to refuse or discontinue treatment at any time.
3. My treatment plan will be developed collaboratively with my provider.
4. I am expected to participate actively in my care, including follow-up visits and lifestyle modifications.

MEDICATION CONSENT – GLP-1 RECEPTOR AGONISTS

If GLP-1 medications (such as semaglutide or tirzepatide) are prescribed, I understand and acknowledge:

• Common side effects include nausea, vomiting, diarrhea, constipation, and decreased appetite.
• Rare but serious risks include pancreatitis, gallbladder disease, and kidney problems.
• These medications carry a boxed warning for thyroid C-cell tumors in animal studies; I will inform my provider if I have a personal or family history of medullary  thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2.
• I will not use GLP-1 medications if I am pregnant, planning to become pregnant, or breastfeeding.
• I must attend required follow-up appointments for monitoring.
• I will report any unusual symptoms to my provider promptly.
• Insurance may not cover this medication and I accept financial responsibility.

MEDICATION CONSENT – PEPTIDE THERAPY
Peptide therapies (such as BPC-157, CJC-1295, Ipamorelin, AOD-9604, and others) may be offered as part of your individualized wellness and weight loss plan. These are compounds that signal various biological pathways related to metabolism, recovery, and body composition. If peptide therapy is prescribed, I understand and
acknowledge the following:

• Regulatory status: Many peptides are compounded medications and are not FDA-approved for the specific indications for which they may be prescribed. Their use is considered off-label. I have been informed of this status and consent to off-label use as part of my individualized treatment plan.
• Compounding pharmacy: Peptides prescribed at this clinic are sourced from licensed, accredited compounding pharmacies. I understand that compounded medications are not subject to the same pre-market approval process as commercially manufactured drugs.
• Possible side effects: Depending on the specific peptide(s) prescribed, side effects may include injection site reactions (redness, swelling, bruising), water retention, fatigue, headache, tingling or numbness, changes in blood sugar, and, for growth hormone secretagogues, potential effects on cortisol or prolactin levels. I will report any adverse reactions to my provider promptly.
• Administration: Peptide therapies are typically self-administered via subcutaneous injection. I will receive
thorough instruction on proper injection technique, storage, and disposal before beginning therapy. I agree to follow all administration instructions as directed.
• Contraindications: I have disclosed all known medical conditions, prior cancers, hormone-sensitive conditions, and current medications. I understand that active malignancy or a history of certain cancers may be a contraindication to growth hormone-stimulating peptides, and my provider has evaluated my
suitability for therapy.

• Monitoring: Baseline and follow-up labs (which may include IGF-1, fasting glucose, lipid panel, and others as clinically indicated) may be required to monitor my response to therapy. I agree to complete all ordered laboratory tests.
• Pregnancy and breastfeeding: I will notify my provider immediately if I am pregnant, planning to become pregnant, or breastfeeding, as peptide therapy is generally not recommended during these periods.
• Insurance coverage: Peptide therapies are typically not covered by insurance and are billed as cash-pay services. I accept full financial responsibility for peptide therapy costs. I understand that no guarantee of specific outcomes has been made.

PHOTOGRAPHY & BODY MEASUREMENTS

Clinical photographs and measurements may be taken for medical documentation of my progress. These records are part of my confidential medical file.

PATIENT RESPONSIBILITIES

1. Attend all scheduled appointments or provide at least 24 hours’ notice to cancel.
2. Provide complete and accurate medical and medication history.
3. Notify the clinic of any changes in health, medications, or pregnancy status.
4. Take medications only as prescribed.
5. Actively participate in recommended lifestyle modifications.

PAYMENT AT TIME OF SERVICE

Payment is due at the time of your visit. We accept the following forms of payment:
☐ Cash ☐ Visa/Mastercard/Discover ☐ American Express ☐ Zelle / Venmo

SELF-PAY RATES
Self-pay rates will be provided to you prior to services rendered. A Good Faith Estimate will be provided upon request in compliance with the No Surprises Act.

MISSED APPOINTMENTS & CANCELLATION POLICY
We require at least 24 hours advance notice to cancel or reschedule an appointment. Late cancellations or no-shows may be subject to a $50 fee per occurrence. Repeated no-shows may result in discharge from the practice.

MEDICAL RECORDS
A fee may be charged for copying and releasing medical records in accordance with Arizona state law.

By signing below, I acknowledge that I have read and understand the financial policy and agree to its terms.

WHAT IS TELEHEALTH?

Telehealth involves the use of electronic communications (video, phone, or secure messaging) to enable health care providers to deliver care when the patient and provider are not in the same physical location. Precision Metabolic Health uses HIPAA-compliant telehealth technology for virtual appointments. Our telehealth platform: Doximity Access link/instructions: Text will be sent to patient prior to appointment.

SCOPE OF TELEHEALTH SERVICES
The following services may be available via telehealth at our clinic:
☐ Initial weight loss consultation ☐ Follow-up visits ☐ GLP-1 medication management
☐ Lab result review ☐ Longevity wellness / Peptides consultation ☐ Longevity wellness / Peptides follow-up ☐ General wellness check-ins

Note: Some services require an in-person visit (e.g., initial physical exam, body composition testing, lab draws, in- office procedures). Your provider will advise you if an in-person visit is necessary.

BENEFITS OF TELEHEALTH
• Convenient access to care from your home, office, or any private location.
• Reduced travel time and costs.
• Increased flexibility in scheduling.
• Continuity of care when in-person visits are not possible.

RISKS AND LIMITATIONS OF TELEHEALTH
I understand and accept the following limitations and potential risks of telehealth:
• Technology failures (internet outage, video/audio issues) may interrupt or prevent a visit.
• A physical examination cannot be performed via telehealth; my provider will rely on information I provide.
• In the event of a medical emergency, telehealth is NOT appropriate — I should call 911 or go to the nearest emergency room.
• Electronic transmission of health information carries a risk of interception, despite security measures.
• Telehealth may not be appropriate for all medical conditions or concerns.
• My provider retains the right to determine whether telehealth is appropriate for any specific visit.

PRIVACY & TECHNOLOGY REQUIREMENTS
I agree to the following for all telehealth visits:
• I will be in a private, quiet location where my conversation cannot be overheard.
• I will not record video or audio of the session without my provider's explicit written consent.
• I will use a device with a working camera and microphone (for video visits).
• I will have a stable internet connection.
• I will not share the secure meeting link with others.
• I understand that the clinic's staff may be present during the visit.

ARIZONA TELEHEALTH REGULATIONS
Arizona permits telehealth services for established and new patient relationships. Prescriptions, including weight loss medications, may be issued via telehealth following a clinically appropriate evaluation in accordance with Arizona state law and applicable federal regulations.
My provider is licensed to practice medicine in the state of Arizona. Telehealth services are provided only to
patients who are physically located within Arizona at the time of the visit, unless otherwise authorized.

TECHNICAL DIFFICULTIES PROTOCOL
If we experience technical difficulties during your telehealth visit, the provider or staff will attempt to:
1. Reconnect within 5 minutes.
2. Switch to a phone call if video cannot be restored.
3. Reschedule the appointment if the visit cannot be completed.

Please have an alternate phone number available.

RIGHT TO WITHDRAW CONSENT
I understand that I may withdraw my consent for telehealth services at any time without penalty or loss of access to in-person care. I may request an in-person visit at any time.

PURPOSE
From time to time, Precision Metabolic Health may wish to use before-and-after p hotographs, testimonials, orcase studies for educational or marketing purposes. This authorization is strictly voluntary and will not affect your medical care in any way.

AUTHORIZATION

I, the undersigned, hereby authorize Precision Metabolic Health and its staff to photograph or record me for the following purposes (check all that apply below):

I understand that:

• My full name will NOT be used without separate written permission.
• I may withdraw this authorization at any time in writing, though images already published may not be retractable.
• I will receive no compensation for use of my photograph or testimonial.
• Photographs will be taken in a professional, dignified manner.
• I am not required to sign this form to receive care.

PROGRAM REQUIREMENTS

To safely prescribe and monitor weight loss medications, including GLP-1 medications and appetite suppressants, you must agree to the following program requirements:

REQUIRED FOLLOW-UP SCHEDULE

PATIENT AGREEMENT

I agree to:

1. Attend all required follow-up appointments. Failure to do so may result in discontinuation of medication.
2. Complete all ordered laboratory tests prior to medication renewal.
3. Report any new symptoms, side effects, or changes in health promptly.
4. Not obtain the same or similar medications from other providers without disclosing this to my treating provider.
5. Not share medications with others.
6. Store medications safely and as directed.
7. Notify the clinic immediately if I become pregnant or am planning pregnancy.
8. Inform all other healthcare providers of my participation in this program.
9. Maintain lifestyle modifications (diet and exercise) as recommended.
10. Understand that medication may be discontinued if I do not follow program requirements.

By signing below, I agree to the terms of this Medication Monitoring Agreement.