Medical & Telehealth Consent
Medical & Telehealth Policy
This Medical and Telehealth Consent Policy is effective as of 06/27/2023.
BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.
IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION CALL 911.
In the event of an adverse reaction to treatment or in the event of an inability to communicate as a result of a technological or equipment failure, contact us at firstname.lastname@example.org or (646) 493-9950.
The purpose of this consent form (“Consent”) is to obtain your informed consent to care and the use of telehealth in the delivery of healthcare to you by physicians, physician assistants, and/or nurse practitioners (“Providers”) using the online platform owned and operated by Modern Age (the “Service”). Modern Age is an integrated multidisciplinary clinic. We incorporate both typical biomedical standards of care as well as Integrated/Regenerative/Aesthetic/Functional Medicine approaches which may not be considered standard for conventional care. By signing up for Modern Age, I authorize providers, their assistants and/or designees to administer any treatment as may be necessary or advisable in my diagnosis and treatment with Modern Age. Modern Age advances this model with the use of telehealth. In this Consent, the terms “you” and “yours” refer to the person using the Service or a person considered of higher age of majority under applicable state law, “you” and “yours” refer to and include (i) the parent or legal guardian who provides consent to the use of the Service by such minor or uses the Service on behalf of such minor, and (ii) the minor for whom consent is being provided or on whose behalf the Service is being utilized.
About Modern Age
This authorization includes, but is not limited to, diet/nutrition therapy inclusive of herbs and supplements, standard and specialized lab options and result interpretation, atypical medication options including but not limited to off-label uses of FDA approved drugs, and specialized or experimental therapies such as platelet-rich plasma, bio-identical hormones, peptides, cosmetic skin treatments and injectables, vitamin injections and IV therapies.
We strive to provide individualized care relevant to your case which could include external referrals or specialized procedures such as regenerative injections, acupuncture, Chiropractic/OMT, biotherapies, and physical medicine. Other ancillary treatments include, but or not limited to laser, red-light therapy, electromagnetic therapy, and other services or procedures, which my provider considers helpful and/or necessary.
My health care providers will discuss with me the risks, benefits and alternatives to recommended treatments. I understand that health care services may be rendered by nurses or other medical professionals such as medical assistants or phlebotomists under supervision. Providing us with copies of any pertinent medical records, including tests and imaging will enhance your care. Although we strive to achieve the best possible results, there is no guarantee of outcomes.
Common treatments include:
Estrogen/Progesterone HRT in Women: We provide an individualized approach to estrogen/progesterone hormone replacement therapy (HRT) which, while not standard, is designed with your specific health needs in mind. While risks, such as increased likelihood of blood clots, stroke, and certain types of cancer, including breast and endometrial, are quite rare, they can occur. Other potential side effects like nausea, mood swings, and weight gain are usually mild and temporary. However, our providers believe that the potential benefits of this therapy, like improved mood and reduced menopausal symptoms, considerably outweigh these rare risks.
Testosterone Replacement in Women: Our unique approach to testosterone replacement therapy in women, though not conventional, is designed to maximize your health and well-being. Possible, but rare, risks include increased risk of cardiovascular disease, acne, unusual hair growth, voice deepening, mood swings, and changes in menstrual cycles. In some cases, there might be an increased risk of insulin resistance. Despite these potential risks, our medical providers believe that the benefits, such as enhanced vitality and libido, far outweigh the rare risks.
Testosterone Replacement in Men: We employ a patient-focused approach to testosterone replacement therapy (TRT) in men, which differs from conventional medical practices. While minor side effects like fluid retention, sleep disturbances, and increased red blood cell count can occur, these are generally rare. Less common but more serious risks, like prostate enlargement and a slight increase in heart disease risk, particularly in older men, may also occur. Despite these potential risks, our healthcare providers believe that the overall benefits, including improved mood, energy, and muscle mass, strongly outweigh the risks.
Low Dose Naltrexone Therapy: While our low-dose naltrexone therapy may not align with the traditional standard of care, it is tailored to fit the needs of our patients. This treatment could occasionally cause fatigue, dizziness, insomnia, and in rare instances, may exacerbate certain mental health conditions like anxiety or depression. However, these instances are usually rare, and our providers believe the benefits, like improved pain management and potential reduction in autoimmune symptoms, far surpass these risks.
Thyroid Hormone Therapy (Armour): Our unique approach with Armour Thyroid, a type of thyroid hormone therapy, is tailored for patient benefit and does not conform to standard guidelines. Potential side effects like heart palpitations, increased appetite, nervousness, sweating, and changes in menstrual cycles are rare but can occur. There's also a rare possibility of overdosage leading to thyrotoxicosis. Nonetheless, our providers strongly believe that the benefits of achieving optimal thyroid function far exceed these potential risks.
GLP-1 Therapy for Weight Loss: Our innovative use of GLP-1 therapy for weight loss provides a distinct, patient-focused approach. Some patients may experience side effects like nausea, vomiting, diarrhea, and in very rare cases, pancreatitis or an increased risk of thyroid tumors. However, these instances are generally rare and our healthcare team believes the potential benefits of weight loss and improved metabolic health strongly outweigh the minor potential side effects.
Metformin Therapy for Weight Loss: While our off-label use of metformin for weight loss does diverge from conventional use, it focuses on the overall health benefits for patients. Possible side effects may include gastrointestinal disturbances, vitamin B12 deficiency, lactic acidosis, and hypoglycemia, but these are generally rare. Our medical providers firmly believe that the advantages of weight loss and improved insulin sensitivity provided by this therapy significantly outweigh the minor and rare potential risks.
Compounded Therapy: Our compounded therapies offer a unique, personalized approach to treatment, which while deviating from standard care, cater to individual patient needs. Minor and rare risks could include adverse reactions due to variable strength and quality of ingredients, or complications from unconventional dosage or method of administration. However, our healthcare team is confident that the potential for personalized and targeted treatment with compounded therapies far outweighs these rare risks.
I acknowledge that no promises or guarantees have been made to me regarding treatment or service rendered by the practice.
Use of Telehealth
Telehealth involves the use of electronic communications to enable providers at different locations to share individual customer information for the purpose of improving customer care. The information may be used for diagnosis, follow-up and/or education, and may include any of the following:
Client health records
Live two-way audio and video
Output data from health devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of customer identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Improved access to care by enabling a customer to remain at a remote site while consulting with practitioners at distant/other sites.
More efficient client evaluation and management.
Obtaining expertise of a distant specialist.
There are potential risks associated with the use of telehealth. These risks include, but may not be limited to:
In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the providers and consultant(s);
Delays in 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 health information;
In rare cases, a lack of access to complete health records may result in interactions or allergic reactions or other judgment errors.
Due to clinician licensing reasons, you have to physically be in the state that your clinician is licensed in during your telehealth visit. By signing this consent, you are confirming that you will only opt in to care when you are in your state of residence or in one of our locations. Furthermore, you are confirming that your state of residence is one in which we are licensed to treat.
By clicking “I Agree”, checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service or otherwise affirmatively accepting this consent, you are agreeing and providing your consent with respect to the following:
I hereby authorize Modern Age to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.
I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.
I accept that the providers can conduct interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
I understand that I will be responsible for any fee associated with the telehealth appointment.
I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.