Telehealth Consent

TELEHEALTH INFORMED CONSENT

DR. MIAMI CLINIC WEIGHT LOSS PROGRAM

Last Updated: January 30, 2026

1. WHAT IS TELEHEALTH?

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up, and/or education, and may include any of the following:

  • Patient medical records
  • Live two-way audio and video
  • Output data from medical devices and sound and video files

2. INDEPENDENT MEDICAL PROVIDERS

By consenting to this form, you understand that Dr. Miami Clinic is an administrative and technology platform. Medical services are provided by independent, licensed healthcare professionals through MD Integrations. Dr. Miami Clinic does not practice medicine and does not interfere with the professional judgment of the clinicians, who are solely responsible for your medical care.

3. EXPECTED BENEFITS

  • Improved access to medical care by enabling a patient to remain in their home or office while the clinician obtains information and provides a clinical evaluation.
  • More efficient medical evaluation and management.

4. POSSIBLE RISKS

  • As with any medical procedure, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:
    • Information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the clinician.
    • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
    • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

5. GLP-1 MEDICATION SPECIFIC RISKS & SIDE EFFECTS

If you are prescribed GLP-1 medications (such as Semaglutide or Tirzepatide), you acknowledge that you have been informed of potential side effects, including but not limited to:

  • Gastrointestinal Issues: Nausea, vomiting, diarrhea, abdominal pain, and constipation.
  • Serious Risks: Gallbladder problems, kidney issues, and pancreatitis.
  • Black Box Warning: You have been informed of the potential risk regarding thyroid C-cell tumors.
  • Pregnancy: You certify that you are not currently pregnant, breastfeeding, or planning to become pregnant while using this medication.

6. NO GUARANTEE OF TREATMENT

You acknowledge that the $99 fee is for a medical consultation. Payment of this fee does not guarantee that a prescription will be issued. The licensed clinician has the sole discretion to determine whether you are a safe and appropriate candidate for the requested medication. If the clinician determines that treatment is not clinically appropriate for you, your request will be rejected.

7. NOT FOR EMERGENCIES

I understand that Dr. Miami Clinic and its telehealth platform are NOT for use in medical emergencies.

If I am experiencing a medical emergency, I will immediately call 911 or go to the nearest emergency room. I understand that my clinician may not be available for immediate response.

8. PATIENT RESPONSIBILITIES & CHAT

  • You agree to provide accurate and complete information about your health and medical history.
  • You understand that you can reach out to your medical provider or the care team at any time via the secure messaging feature in the Patient Portal.
  • You agree to follow the treatment plan as visualized and documented by your doctor in the portal.

9. WITHDRAWAL OF CONSENT

I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that withdrawing consent may result in the termination of my subscription to the Dr. Miami Weight Loss Program.

10. PATIENT ACKNOWLEDGMENT

By clicking the “I Agree” checkbox on the registration form, I certify that:

  1. I have read this form and understand the risks and benefits of telehealth.
  2. I have had my questions regarding telehealth answered.
  3. I hereby give my informed consent to participate in a telehealth consultation under the terms described above.