Purpose: This form explains your rights and responsibilities regarding care provided via
telehealth.
Definition of Telehealth: Telehealth refers to healthcare services provided remotely via secure
video or phone communication.
What to Expect:

•  You will receive medical advice, diagnosis, or treatment through telecommunication
  technology.
•  All information is confidential and complies with HIPAA privacy laws.
• You may be asked to complete lab work at an approved local laboratory.

Benefits:

•  Convenience and access to care without travel.
• Access to specialists regardless of location.

Risks:

• Technology failure or disruption.
• Delays due to incomplete information or inability to examine certain areas in-person.

Your Rights:

• You may stop or decline telehealth services at any time.
• You have the right to access your medical records.

Your Responsibilities:

• Provide accurate information and updates to your provider.
• Ensure a private, secure environment for your sessions.
• Follow up with lab tests, imaging, or referrals as advised.

Consent Acknowledgment: By signing below, I confirm that:

• I understand the risks and benefits of telehealth.
• I consent to receive medical services via telehealth.
• I understand I may withdraw consent at any time

"Consent Acknowledgment: By signing below, I confirm that..."

Purpose: This form outlines the potential benefits, risks, and responsibilities associated with
Hormone Replacement Therapy (HRT) and Bioidentical Hormone Replacement Therapy
(BHRT).
Benefits of HRT/BHRT May Include:

• Relief of menopausal/andropausal symptoms
• Improved energy and mood
• Increased libido and sexual function
• Support for bone density and cardiovascular health
• Enhanced cognitive clarity and overall well-being

Potential Risks and Side Effects:

• Acne or oily skin
• Breast tenderness or enlargement
• Mood swings, anxiety, or irritability
• Increased red blood cell count (testosterone)
• Blood clots (rare, typically with oral estrogen)
• Fluid retention, weight changes
• Virilization (in women taking testosterone)

Monitoring: I understand that regular lab tests and follow-up visits are necessary for safe and
effective treatment. These include hormone levels, CBC, PSA (men), lipid panels, and others as
needed.

Medication Use: I agree to use medications only as prescribed and to report any adverse effects
immediately. I will not share or sell any prescribed hormone medications.

Contraindications: I confirm that I have disclosed any personal or family history of cancer,
blood clots, heart disease, or other relevant conditions. I understand that HRT may not be
recommended for individuals with certain medical histories.

Voluntary Participation: I understand that HRT/BHRT is elective and that I may stop treatment
at any time. I acknowledge the therapy is tailored to individual symptoms and labs and may
require dose adjustments over time.

Consent Acknowledgment: I have read and understood the above. I have had the opportunity to
ask questions, and my questions have been answered to my satisfaction. I consent to initiate or
continue hormone therapy under the guidance of my provider

"Consent Acknowledgment: By signing below, I confirm that..."

Purpose: To inform you of your rights under the Health Insurance Portability and
Accountability Act (HIPAA) and acknowledge receipt of our privacy practices.

Your Rights Under HIPAA:

• You have the right to review and receive a copy of your medical records.
• You can request amendments to your health records.
• You can request limits on the use and disclosure of your information.
• You can request confidential communications.
• You can receive a list of disclosures of your health information.

Our Responsibilities:

•  We are required by law to maintain the privacy and security of your protected health
  information (PHI).
• We will notify you promptly if a breach occurs that may have compromised your PHI.
• We must follow the duties and privacy practices described in our Notice of Privacy
  Practices.

Acknowledgment: I acknowledge that I have been offered a copy of the Notice of Privacy
Practices and that I understand my rights related to the confidentiality and use of my medical
records.

"Consent Acknowledgment: By signing below, I confirm that..."

Effective Date: 5/8/2025
This agreement outlines the terms and conditions for payments made by patients receiving
services at Rejuvaris Hormone and Urgent Care Clinic.

1.  Payment Terms
   
   • A non-refundable deposit of 30% of the total service cost is required at the time of booking to secure all appointments and services.
   • The remaining 70% balance is due in full at check-in on the day of the scheduled service.
2.  Accepted Payment Methods
   
   • We accept credit/debit cards, Venmo, Cash App, and Zelle for online, phone, and in-person visits.
   • Cash is not accepted for telehealth visits.
   • All payment methods must be verified and processed before services are rendered.
3. Cancellations & Rescheduling
   • Appointments canceled or rescheduled with less than 24 hours' notice may result in forfeiture of the deposit.
   • Patients arriving more than 15 minutes late may need to reschedule and will be subject to the cancellation policy.
4. Acknowledgment

By signing below, you acknowledge and agree to the above payment terms and conditions

Effective Date: 5/8/2025
This form outlines your responsibilities regarding insurance copayments and authorizes
Rejuvaris Hormone and Urgent Care Clinic to collect applicable fees.

1. Copayment Policy
   
   • I understand that my insurance plan may require a copayment for services rendered.
   • I agree to pay the required copay at the time of service, whether my visit is in-person or virtual.
   • I acknowledge that failure to pay the required copay at check-in may result in the rescheduling of my appointment or the addition of a late fee.
2. Responsibility for Payment
   
   • I understand that copays are set by my insurance provider, and it is my responsibility
     to know and understand my plan’s requirements.
   • I agree that I am financially responsible for any copay, coinsurance, or deductible
     amounts not covered by my insurance.
3. Payment Methods
   
   • Copayments may be made using credit/debit card, Venmo, Cash App, or Zelle.
   • Cash is not accepted for telehealth visits.
4. Acknowledgment

By signing below, I acknowledge that I have read, understand, and agree to the terms of this Insurance Copay Consent.