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HEALTH CARE SERVICES CONSENT

I understand by signing this Health Care Services Consent (“Consent”), I give my consent to receive professional health care services from Amazing Meds rendered by a health care provider that treats me through a telehealth platform. Professional care may include, but not be limited to, review of information I have provided or questions answered prior to a telehealth examination, a telehealth examination or consultation, prescription of medication, and provision of any follow-up care, as needed. I understand Amazing Meds is a telehealth medical practice; and I may receive treatment from multiple providers, my protected health information may be shared among the providers in connection with my treatment and pursuant to the Practices’ privacy policies.

I allow Amazing Meds, from which I receive services, to obtain access to my medication history for treatment purposes, through integrative electronic prescribing platforms and/or computer networks operated by providers of electronic prescribing services. I understand that I may withhold or withdraw my consent regarding access to my medication history through the electronic prescribing platforms and/or computer networks per the process described below, which will not affect my ability to receive medical care.

I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury and/or a serious adverse event. I understand that there are risks and benefits when receiving any health care services and that the risks and benefits of such care will be explained to me, and I will have the opportunity to ask my health care providers questions about such risks and benefits. Services rendered by Amazing Meds Providers are not intended to replace my primary care medical services.

I acknowledge that no guarantees have been made to me regarding the result of a diagnosis or treatment provided to me by my Amazing Meds Provider. As with any other medical services, some patients do not respond to prescribed treatment.

I have disclosed all my known health conditions, allergies, and medications/supplements I am taking. I understand that certain treatment options that I may receive from or medications prescribed to me by my Amazing Meds Practice Provider can be dangerous and may result in medical care that is unnecessary if I have misrepresented my current health care condition and status. I have truthfully supplied information about my health care condition and status in response to any health-related questions prior to, during any in-person examination with my Amazing Meds Provider, and after an exam.

I understand that the terms herein are contractual and not a mere recital and that I sign to agree with this document as my own free act and not of any coercion. The permissions granted herein shall begin on the date I agreed to this document and shall remain effective until terminated by me. I understand I have the right to withhold/withdraw my consent at any time by submitting a request via email to [email protected].

I verify I have read all of the information contained in this Consent. I understand I will have the opportunity to ask my Amazing Meds Provider about anything I have not understood up to this point.