Testosterone Shots
Telehealth Medical Consent

TestosteroneShots.com PC (DBA: TestosteroneShotscom)

Last updated: October 8, 2024

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DIAL 1-800-273-TALK

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I. Introduction

You are reviewing and acknowledging this Telehealth Informed Consent because you are seeking Healthcare Services utilizing telehealth technologies by the TestosteroneShots.com PC facilitated through the Testosterone Shots Platform website, iOS mobile app, web mobile app or other telehealth technologies collectively the “Testosterone Shots Platform.” This Telehealth Informed Consent does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of Testosterone Shots or the Providers, rather it supplements these terms and documents.

By creating an account, starting a consult, clicking “I consent to telehealth,” checking a related box to signify your acceptance, or using any other acceptance protocol presented through the Testosterone Shots Platform, you indicate that you have reviewed the risks as described herein of receiving services utilizing telehealth technologies and consent to receiving the services. A record of this Telehealth Informed Consent is maintained in the files and records of the applicable Provider delivering your services, and your on-going participation in services by the TestosteroneShots.com PC using telehealth technologies serves as an on-going acknowledgement of your acceptance of this Telehealth Informed Consent and updates at such time the representations you provide herein.

TestosteroneShots.com PC refers to a network of medical professional organizations affiliated with Testosterone Shots Platform and its employed and contracted health providers (the “Providers”).

II. What is Telehealth?

Telehealth involves the delivery of health and wellness services using electronic communications, information technology, or other means between a licensed, certified, or registered healthcare professional at one location and a patient in another location about a clinical matter. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education. These telehealth services may involve various modalities, including asynchronous interactions, real-time (synchronous) video and audio encounters, and interactive audio with store and forward. This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of utilizing telehealth to meet your health and wellness needs.

III. What are the Possible Benefits of Telehealth?

Benefits of telehealth include being easier and more efficient for you to access health and wellness services. You can obtain health and wellness services at times that are convenient for you without the necessity of an in-office appointment, including follow-up care related to your treatment. If you need follow-up care, please contact us through the Testosterone Shots Platform or the Testosterone Shots call center at

323-283-9219, Mon - Sun 4:00 am PST - 5:00 p.m PST

IV. What are the Possible Risks of Telehealth?

Information transmitted to your health professional may not be sufficient to allow for appropriate health or wellness services to meet your particular need. Some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. The technology necessary to interact with your health professional may fail and delay your services. If a technical failure prevents you from communicating with your Providers, you should call the following number:

Phone: 323-283-9219 Mon - Sun 4:00 am PST - 5:00 pm PST

In rare events, a lack of access to complete medical records, and/or the quality of transmitted data could result in adverse drug interactions, allergic reactions, and/or other clinical judgment errors. You may stop or decline any on-going Healthcare Services provided by TestosteroneShots.com PC using telehealth technologies at any time, although you acknowledge that applicable fees may apply if a medical consultation has occurred prior to request to cancel services and TestosteroneShots.com PC has no obligation for your on-going care or selection of separate healthcare services in such circumstances.

I understand that certain diagnostic testing services, including laboratory products and services offered through the Testosterone Shots Platform to support the Healthcare Services of Providers, may contain defects, including ones which may limit functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that I receive from my Provider(s).

THIRD-PARTY LABORATORY PRODUCTS AND SERVICES To facilitate certain Healthcare Services Providers may require that you complete diagnostic test(s). These diagnostic tests are provided by third-party laboratories, and neither Testosterone Shots, TestosteroneShots.com PC, nor your Provider(s) can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact your Provider(s) ability to correctly diagnose or treat your medical conditions. A failure or defect of these tests could also impact your Provider(s) ability to correctly diagnose or treat your medical conditions.

V. Patient Acknowledgments

By accepting this Telehealth Informed Consent, you acknowledge you understand and consent to the following:

You have reviewed this Telehealth Informed Consent carefully, and understand there are risks, limitations, and benefits of utilizing telehealth.

You understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my health information.

In some cases, my Provider may be a nurse practitioner or physician assistant and not a physician.

Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies and/or for language translation assistance, if requested. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his or her role.

I understand that information I provide as part of any telehealth offering is viewed as accurate, true, and complete.

I understand that in certain instances, and in compliance with applicable law, my Provider may determine that it is appropriate to provide my Healthcare Services asynchronously via store-and-forward technology. In such instances, my Provider and I will communicate electronically through the Testosterone Shots Platform and not via telephone or video. I agree that if my provider makes that determination, I would like to receive Healthcare Services in this manner.

I understand that there is no guarantee that I will be given a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. I understand that while the use of telehealth may provide benefits to me, no such benefits or specific results can be guaranteed and my condition may not improve.

I understand there is a risk of technical failures during the telehealth encounter beyond the control of TestosteroneShots.com PC and my Provider(s). I AGREE TO HOLD HARMLESS TestosteroneShots.com PC AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, INCLUDING TESTOSTERONE SHOTS AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.

I understand the Testosterone Shots Platform makes available a specific set of services and I may need to seek other resources for my other health needs. There is no guarantee that I will be approved for treatment by a Provider. My Provider reserves the right to deny care for any reason if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth is not medically or ethically appropriate. I understand that the Providers, and not Testosterone Shots or the TestosteroneShots.com PC, are responsible for the quality and appropriateness of the care they render to me and make all decisions regarding clinical care in their independent discretion without the influence of Testosterone Shots or the TestosteroneShots.com PC. I agree to only seek relief against the Provider for any liabilities pertaining to medical or clinical issues arising as a direct result of medical or clinical services accessed through Testosterone Shots

I understand that by using the Testosterone Shots Platform I am not always speaking or messaging with my Provider in real-time, and there may be a delay before my messages or information is reviewed. I understand that I must check the Testosterone Shots Platform for messages because this is the way that my Provider will communicate important information to me. I understand that if I do not check the Testosterone Shots Platform regularly, then my services may be delayed.

I understand that I have the opportunity to discuss the use of telehealth, including the Healthcare Services, with my Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. I have the right to withdraw my consent to the use of telehealth in the course of my care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who provide Healthcare Services via the Testosterone Shots Platform do not offer in-person treatment.

I understand that I have access to my medical record pertaining to the Healthcare Services of Providers utilizing the Testosterone Shots Platform in accordance with applicable laws and regulations and that my primary care provider, or other treating provider, may obtain copies of my health and wellness information with my consent.

I understand that while the Testosterone Shots Platform may make available access to pharmacy or diagnostic lab services that are coordinated with the Healthcare Services, I am able to request any pharmacy or lab of my preference.

I agree that Adonis is a third-party beneficiary of the Telehealth Patient Consent and has the right to enforce it against you.

VI. Additional State-Specific Disclosures

The following disclosures apply to users accessing the Testosterone Shots Platform for the purposes of participating in a telehealth visit as required by the states listed below:

Iowa

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://medicalboard.iowa.gov/consumers/filing-complaint.

Kentucky

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://kbml.ky.gov/grievances/Pages/default.aspx.

Maine

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://www.maine.gov/md/complaint/file-complaint.

New York

I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit here: https://www.health.ny.gov/professionals/doctors/conduct.

Oregon

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://www.oregon.gov/omb/investigations/pages/how-to-file-a-complaint.aspx.

Rhode Island

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://health.ri.gov/complaints/.

Texas

I have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS- Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us

Vermont

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; or Board of Osteopathic Examiners can be found at: https://sos.vermont.gov/opr/complaints-conduct-discipline/

Wyoming

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: http://wyomedboard.wyo.gov/consumers/file-a-complaint.

Florida

Informed Consent Related to Treatment of Weight Loss Conditions Through Telehealth

Purpose: Pursuant to Florida Medical Board Rule, Standards for the Prescription of Drugs to Treat Obesity (64B8-9.012(5)), licensees, before prescribing, ordering, dispensing, or administering an anti-obesity drug, must obtain written informed consent from the patient discussing “potential benefits versus potential risks of weight loss treatments”. A copy of the signed informed consent shall be included in the patient’s medical record.

This draft consent document is meant to capture the required statements around “potential benefits versus potential risks of weight loss treatment”. The Rule does not require this consent to include any specific language.

Purpose. The purpose of this informed consent form is to ensure you are aware of the potential benefits and risks of starting a weight-loss program.

It is vitally important for you to advise your health provider(s) of ANY concerns, problems, complaints, symptoms, or questions, even if you may think it is not terribly important, so the provider team can determine the best course of treatment. Keeping your healthcare team informed of any questions or symptoms you have affords the best chance of providing you with necessary information and developing a path forward.

Potential Benefits

Medically significant weight loss (usually about 10 percent of initial weight, or as an example, losing 20 pounds from 200 pounds starting weight) can:

Lower blood pressure reduces the risk of hypertension.
Lower cholesterol reduces the risks of heart and vascular disease.
Lower blood sugar reducing the risks of diabetes

If you are taking medications for one or more of these conditions, dosages may need to be adjusted as your overall health improves. You agree to see your primary care provider, if you have one, as needed to have your need for these medications reassessed, if applicable.

Other benefits may also be obtained but cannot be guaranteed. Increasing activity level can favorably affect the above conditions and may have the additional benefit of helping you sustain weight loss. Weight loss and increased activity may provide important psychological and social benefits, as well.

Possible Side Effects and Risks

The possibility always exists in medicine that the combination of any significant disease with methods employed for its treatment may lead to previously unobserved or unexpected ill effects, including death. Should one or more of these ill effects occur, additional medical or surgical treatment may be necessary. In addition, it is conceivable that other side effects could occur, which have not yet been diagnosed or observed.

Reduced Weight. When you reduce the number of calories you eat to a level lower than the number of calories your body uses in a day, you lose weight. As a result of this weight loss, your body makes some other adjustments in body processes. Some of these adjustments are responsible, in some participants, for improvements in blood pressure and blood sugar. However, you also may experience other temporary side effects or discomforts, including an initial loss of body fluid through increased urination, momentary dizziness, a reduced metabolic rate or metabolism (the rate at which you convert food to energy), sensitivity to cold, a slower heart rate, dry skin, fatigue, diarrhea or constipation, bad breath, muscle cramps, a change in menstrual pattern, dry and brittle hair or hair loss. Generally, these responses are temporary and resolve when calories are increased after the period of weight loss.

Reduced Potassium Levels. Low potassium levels can cause serious heart irregularities. When someone has been on a reduced-calorie diet, a rapid increase in calorie intake, especially overeating or binge-eating, can be associated with bloating, fluid retention, disturbances in salt and mineral balance, or gallbladder attacks and abdominal pain.

Gallstones. Overweight people develop gallstones at a rate higher than normal weight individuals. The occurrence of symptomatic gallstones (pain, diagnosed stones, and/or surgery) in individuals 30 percent or more over desirable body weight (50 pounds or more overweight) not undergoing current treatment for obesity is estimated to be 1 in 100 annually, and for individuals who are 20-30 percent overweight, about one-half that rate, or 1 in 200 annually. It is possible to have gallstones and not know it. One study of individuals entering a weight loss program showed that as many as 1 in 10 had "silent" gallstones at the onset. As body weight and age increase, so do the chances of developing gallstones. These chances double for women, women using estrogen, and smokers. Losing weight--especially rapidly--may increase the chances of developing stones or sludge and/or increasing the size of existing stones within the gallbladder. The most common symptoms of gallstones are fever, nausea, and cramping pain in the right upper abdomen. If you develop any of these symptoms or if you know or suspect that you may already have gallstones, let your provider team and primary care provider know immediately. Gallbladder problems may require medication or surgery to remove the gallbladder, and, less commonly, may be associated with more serious complications of inflammation of the pancreas or even death.

Pancreatitis. Pancreatitis, or an inflammation or infection in the bile ducts, may be associated with the presence of gallstones and the development of sludge or obstruction in the bile ducts. The symptoms of pancreatitis include pain in the left upper abdominal area, nausea, and fever. Pancreatitis may be precipitated by binge-eating or consuming a large meal after a period of dieting. Also associated with pancreatitis is long-term abuse of alcohol and the use of certain medications, and increased age. Pancreatitis may require surgery and may be associated with more serious complications and death.

Pregnancy. If you become pregnant, you should immediately stop any and all of your weight loss medications and report this to your healthcare team and primary care provider, if applicable, immediately. Your diet must be changed promptly to avoid further weight loss because a restricted diet could be damaging for a developing fetus. You must take precautions to avoid becoming pregnant during the course of weight loss.

Binge Eating Disorders. Binge eating disorder is defined as the habitual, uncontrolled consumption of a large amount of food in a short period of time. Participation in a calorically restricted diet has been shown in one study to increase binge eating episodes temporarily. Several other studies have demonstrated reduced episodes of binge eating following a calorie-deficient and portion-controlled diet. Extended binge eating episodes are associated with weight gain.

The Risk of Weight Regain. Obesity is a chronic condition, and the majority of overweight individuals who lose weight tend to regain all or some of it over time. Factors that help to maintain a reduced body weight include regular physical activity, adherence to a restricted-calorie, low-fat diet, and planning a strategy for coping with weight regain before it occurs. Successful treatment may take months or even years. Medical studies of calorie-deficient/portion-controlled diets (including modified fasting) have shown varying results for patients who maintain weight loss. Some studies have shown that fewer than 5% of weight loss patients were able to maintain a reduced body weight after five years. Another study showed that after three years, weight loss patients, on average, maintained about half of their initial weight loss. If you have had fluctuations in your weight in the past, it may be more difficult to maintain the weight you lose during and after this program. A published medical study indicated that people whose body weight fluctuates greatly or often have a higher risk of heart disease and death compared with persons of relatively stable body weight, and such weight fluctuations may play a role in the development of other chronic diseases.

Sudden Death. Patients with severe obesity, particularly those with serious hypertension, coronary artery disease, or diabetes mellitus, have a statistically higher chance of suffering sudden death when compared to normal-weight people without such medical problems.