Please sign below to acknowledge that you agree and understand the following:

You have reported any history of pancreatitis, gallbladder disease, gastroparesis or diabetes.

You have no personal or family history of medullary thyroid cancer or multiple endocrine neoplasia.

You have reported and will discuss any history of thoughts of wanting to hurt yourself (now or ever) and call 911 if any current thoughts of suicidality or self harm arise.

Females- You are not breastfeeding, pregnant or planning on becoming pregnant.

FEMALES - YOU WILL USE BACKUP CONTRACEPTION WITH ORAL CONTRACEPTIVES.

Patient Informed Consent

I voluntarily request that my provider through Active Medical Solutions treats my medical condition.

I have informed my provider of any and all known allergies, my medical conditions, medications, social and family history.

I understand how it is to be administered, which may be by injection under the skin.

I understand the prescription will come from a compounding pharmacy. I have been informed that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself but the base chemical is not a generic medication.

Prices may vary and change per the dispensing compounding pharmacy. We have no affiliation with the pharmacy and collect funds on their behalf. We retain no portion of those funds.

No refunds will be processed for the medication once the prescription has been sent. You may incur a change fee if we are able to change or cancel the prescription. If you choose not to take the medication, please contact the dispensing pharmacy for proper disposal procedures.

It has been explained to me that this medication could be harmful if taken inappropriately or without advice from the provider.

I understand this, like any medication may cause adverse side effects (see below). I understand this list is not complete and it describes the most common side effects, and that death is also a possibility of taking this or any medication.

Serious Reactions or concerns include, but are not limited to:

Multiple Endocrine Neoplasia

Medullary thyroid cancer

Hypersensitivity reaction

Anaphylaxis

Angioedema

Acute kidney injury

Pancreatitis

Cholelithiasis

Cholecystitis

Syncope

Other unforseen complications

I have read this form in its entirety. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment and agree to the risks.

Last Updated: March 27, 2025

USER REPRESENTATIONS: You represent and warrant that you are at least eighteen (18) years of age to register on the Site, to enroll for the Services and/or use the Services. You further represent and warrant that: (i) you have the legal ability and authority to agree to these Terms of Use and use the Site and Services; (ii) the information you provided during your registration is accurate and complete; (iii) you will comply with all applicable laws as they relate to the Site and/or Services; and (iv) you will not interfere with, disrupt, or replicate, or attempt to interfere with, disrupt, or replicate this Site and Services and its security measures and protocols. If any information you provided to us becomes inaccurate, incomplete, or otherwise false and/or misleading, you will immediately notify us. You are responsible for ensuring that any information you provide is complete, up to date, and accurate.

MODIFICATION OF SITE AND SERVICES: We reserve complete and sole discretion with respect to the operation of the Site and the Services. We may withdraw, suspend, or otherwise discontinue any functionality or feature of the Site or the Services. We reserve the right to maintain, delete, or destroy all communications and user content posted or uploaded to the Services pursuant to applicable law and our internal record retention and/or destruction policies. Occasionally, we may perform maintenance on or upgrade the Site or Services or the underlying structure that enables use of the Site or Services. This may require us to temporarily suspend or limit your use of the Site or Services until such time the maintenance or upgrade is completed. To the extent possible and unless otherwise stated, we will endeavor to publish the time and date of such expected suspension or limitation of the Site or Services in advance when possible. You agree that you are not entitled to claim any damages for such suspension or limitation during such maintenance or upgrade.

USE OF SERVICES: You are required to provide us with your name, email address, and phone number upon registering for a user account. We will use your email address or phone number to send you important updates about the Site and Services, as well as notifications when information and documents are added that you need to be aware of (e.g. forms, updated terms, etc.). In some instances, but not all, registered users may be permitted to opt out of receiving certain emails.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

WHO WILL FOLLOW THIS NOTICE:

This notice addresses the use of your medical information by your physician (the “Practice,” “we” or “us”) and its business associates. 

We may use your medical information, also known as protected health information (“PHI”), for treatment, payment, operations, or research purposes as described in this notice. All employees of the Practice follow these privacy practices. The practitioners on our staff will also follow this notice when they work at the Practice. 

ABOUT THIS NOTICE

This notice will tell you about the ways we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• make sure that medical information that identifies you is kept private;

• give you this notice of our legal duties and privacy practices with respect to your medical information; 

• follow the terms of the notice that is currently in effect; and

• notify individuals, either known or reasonably believed to be affected, following a breach of unsecured protected health information.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and give examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one or more of the categories.

• For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to physicians, nurses, technicians, medical students or other Practice personnel who are involved in your care. Different departments and personnel of the Practice also may share medical information about you to coordinate the different services you may need, such as prescriptions, lab work and imaging services. We also may disclose medical information about you to people outside the Practice who may be involved in your medical care.

• For Payment. We may use and disclose medical information about you so that we may bill for treatment and services you receive at the Practice and collect payment from you, an insurance company or another party. For example, we may need to give information about the medical care you received at the Practice to your health plan so that the plan will pay us or reimburse you for the applicable treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may also disclose information about you to other healthcare facilities for purposes of payment as permitted by law.

• For Healthcare Operations. We may use and disclose medical information about you for operations of the Practice. These uses and disclosures are necessary to run the Practice and make sure that all of our patients receive quality care. For example, we may use medical information to evaluate the performance of our staff in caring for you or the outcome of your treatment. We may also combine medical information about many patients to decide what additional services the Practice should offer, what services are not needed and whether certain new treatments are effective. We may also combine medical information we have with medical information from other practices to compare our performance and to make improvements in the care and services we offer. We may also disclose information to doctors, nurses, technicians, medical students, and other Practice personnel for educational purposes. We may also disclose information about you to other healthcare facilities as permitted by law.

• Appointment Reminders. We may use and disclose medical information to contact you to remind you that you have an appointment for treatment or medical care.

• Treatment Alternatives. We may use and disclose medical information to tell you about possible treatment options that may be of interest to you.

• Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you

• Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

• Research. In certain circumstances, we may use and disclose PHI about a patient for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects, however, are subject to an approval process. This process evaluates a proposed research project and its use of PHI to balance research needs with patients’ needs for privacy. Before we use or disclose PHI for research, the project will be approved through this process. However, we may disclose medical information a patient to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the PHI they review does not leave the Practice premises. When required by law, we will ask for specific written authorization if the researcher will: (i) have access to a patient’s name, address or other information that reveals who the patient is, or (ii) be involved in patient care at the Practice.

• As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.

• To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

SPECIAL SITUATIONS

• State Law. In certain states, special privacy protections apply to certain information, including genetic, sexually transmitted disease, or mental health information. Some parts of this general Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, and if applicable state laws govern, such information will be further protected pursuant to applicable state law. For further information, please contact us using the contact information listed on the last page of this Notice.

• Drug and Alcohol Abuse Information.  The confidentiality of alcohol and drug abuse patient records is protected by Federal law and regulations. Generally, a health care provider may not say to a person outside a treatment program that a patient attends a program, or disclose any information identifying a patient as an alcohol or drug abuser unless: 

• The patient consents in writing:

• The disclosure is allowed by a court order; or

• The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

• Organ and Tissue Donation. If you are an organ or tissue donor, we may release medical information about you to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank.

• Military and Veterans. If you are a member of the armed forces of the United States or another country, we may release medical information about you as required by military command authorities.

• Workers' Compensation. We may release medical information about you for workers' compensation or similar programs.

• Public Health Risks. We may disclose medical information about you to authorized public health or government officials for public health activities. These activities generally include the following:

• to a person subject to the jurisdiction of the Food and Drug Administration (FDA) for purposes related to the quality, safety or effectiveness of an FDA-regulated product or service;

• to prevent or control disease, injury or disability; 

• to report disease or injury;

• to report births and deaths;

• to report child abuse or neglect;

• to report reactions to medications and food or problems with products;

• to notify people of recalls or replacements of products they may be using;

• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

• Health Oversight Activities. We may disclose medical information about you to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.

• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request or other legal demand by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

• Law Enforcement. We may release medical information about you if asked to do so by a law enforcement official:

  • in response to a court order, subpoena, warrant, summons or similar process;

  • to identify or locate a suspect, fugitive, material witness or missing person;

  • about the victim of a crime if, under certain circumstances, we are unable to obtain the person’s agreement;

  • about a death we believe may be the result of criminal conduct;

  • about criminal conduct at the Practice or by healthcare providers affiliated with the Practice;

  • in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime; and

  • to authorized federal officials so they may provide protection for the President and other authorized persons or conduct special investigations.

• Coroners, Medical Examiners and Funeral Directors. We may release medical information about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information to funeral directors so they can carry out their duties.

• National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

• To a School. We may disclose information to a school, about an individual who is a student or prospective student of the school, if: 

  • The protected health information that is disclosed is limited to proof of immunization; 

  • The school is required by State or other law to have such proof of immunization prior to admitting the individual; and 

  • The covered entity obtains and documents the agreement to the disclosure from either: 

    • A parent, guardian, or other person acting in loco parentis of the individual, if the individual is an un-emancipated minor; or 

    • The individual, if the individual is an adult or emancipated minor.

• Other Uses and Disclosures.  Other uses and disclosures not described in this Notice will be made only with your written authorization, and you may revoke such authorization provided under this section at any time, provided that the revocation is in writing, except to the extent that we have taken action(s) in reliance upon your authorization; or if the authorization was obtained as a condition of obtaining insurance coverage. 

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records. This right does not include psychotherapy notes, information compiled for use in a legal proceeding or certain information maintained by laboratories. In order to inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer listed at the end of this Notice. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to medical information, you may request in writing that the denial be reviewed. To request a review, contact the Privacy Officer. A licensed healthcare professional will conduct the review. We will comply with the outcome of the review.

• Right to Amend. If you think that the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Practice. To request an amendment, your request must be made in writing and submitted to the Privacy Officer, listed on the last page of this Notice, for the location at which you were treated. In addition, you must give a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

  • was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

  • is not part of the medical information kept by or for the Practice;

  • is not part of the information that you would be permitted to inspect and copy; or 

  • is accurate and complete.

We will provide you with written notice of action we take in response to your request for an amendment.

• Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of medical information about you. We are not required to account for any disclosures you specifically requested or for disclosures related to treatment, payment or healthcare operations or made pursuant to an authorization signed by you. To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer. This contact information is listed at the last page of this Notice. Your request must state a time period, which may not be longer than six years. We will attempt to honor your request. If you request more than one accounting in any 12-month period, we may charge you for our reasonable retrieval, list preparation and mailing costs for the second and subsequent requests. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

• Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. Additionally, you can request restrictions on medical information disclosed to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the information pertains solely to a health care item or service for which you, or person other than the health plan on your behalf, has paid us in full.  To request a restriction, you must contact the Privacy Officer. This contact information is listed on the last page of this Notice.

• We are not required to agree to your request. If we agree to your request, we will comply with your request unless the information is needed to provide you emergency treatment.  You may terminate the restriction at any time.  If we terminate the restriction, we will notify you of the termination.  We are not able to terminate or refuse your request for restrictions to disclosures to health plans if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the information pertains solely to a health care item or service for which you, or person other than the health plan on your behalf, has paid us in full.

• Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must submit a written request to the Privacy Officer. This contact information is listed at the end of this Notice. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will attempt to accommodate reasonable requests.

• Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice upon written request from the Practice or at your first treatment encounter with the Practice. You may get an additional copy of this Notice at any time by contacting us. This contact information is listed at the end of this Notice.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information about you we already have as well as any information we receive in the future. We will post copies of the current Notice at the Practice. The Notice will contain the effective date. In addition, each time you register with the Practice for treatment or healthcare services, we will make available copies of the current Notice. Any revisions to our Notice will also be posted on our website.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services, Office of Civil Rights. To file a complaint with the Practice, please call or write to the Privacy Office. This contact information is listed at the end of this Notice. You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not described in this Notice or the laws that apply to us will be made only with your written authorization on a Practice authorization form. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. However, we may continue to use or disclose that information to the extent we have relied on your authorization. You also understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you. 

HIPAA Notice of Privacy Practices

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The Notice of Privacy Practices describes how Protected Health Information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

We are required by law to protect the privacy of health information that may reveal your identity, and to provide you with a copy of this notice, which describes the health information privacy practices of our practice, its medical staff, and affiliated health care providers that jointly perform payment activities and business operations with our Practice. “Protected Health Information” is information about you, including demographic information that may identify you and genetic information, and that relates to your past, present or future physical or mental health or condition and related health care services.

FOR MORE INFORMATION OR FURTHER QUESTIONS PLEASE CONTACT:

Practice Name:    Active Medical Solutions

Address:        1032 E Brandon Blvd #2126

                         Brandon, FL 33511

Privacy Officer Vidrine

Contact Information: help @ amsdoc. com

Telemedicine is the delivery of healthcare services when the healthcare provider and the patient (the “Patient”) are not in the same physical location and communicate through technology. Electronically transmitted information may be used for diagnosis, treatment, follow-up, prescribing, or education and may include medical records, medical images, interactive audio, video and/or data communications, and output data from medical devices, sound and video files.

The Patient is hereby advised that the care provided by practitioners through Active Medical Solutions and contracted providers (the “Practice”) is not a replacement for an in-person primary care relationship with a physician. If the Patient does not have a primary care practitioner, they are advised to seek the care of one.

The Patient understands the following with respect to telehealth offered by the Practice:

The Patient has elected to have a telehealth visit instead of an in-office visit at the Practice. The Patient agrees that the Practice will determine whether the Patient’s condition is appropriate for telehealth and acknowledges that the Practice may recommend an in-person visit.

The Patient has had an opportunity to review the Practice’s providers’ credentials and selected his or her preference for provider.

There are potential risks associated with the use of telehealth, including, but not limited to: the information transmitted may be less comprehensive than that available during an in-person visit and may therefore result in decreased accuracy of diagnosis or medical decision-making; delays in medical evaluation or treatment could occur due to deficiencies or failures of the telemedicine equipment; security protocols could fail, causing a breach of privacy.

The Patient understands that telehealth often involves electronic transmission of the Patient’s protected health information (“PHI”). The Patient’s PHI includes, but is not limited to, the Patient’s identifying information; medical history; diagnoses; communications to and from the Patient’s other health care provider(s); etc. The Patient understands that PHI may be lost due to technical failures, cyber intrusion or other issues disrupting the Patient’s telehealth visit or causing delays in response from the Practice. The Patient assumes these risks and holds the Practice and its providers harmless from any claims arising out of the use of telehealth to conduct the visit. The Patient understands that PHI obtained during the telehealth visit will not be disclosed to others without the Patient’s consent unless permitted by applicable law and in accordance with the Practice’s Notice of Privacy Practices.

The Patient has the right to request that we submit information about his or her treatment with the Practice to his or her primary care physician. If the Patient makes such a request and consents to the disclosure of PHI, the Practice will send the Patient’s medical record, and/or a report containing an explanation of the Patient’s treatment, to the Patient’s primary care physician within 72 hours of his or her consultation with the Practice.

The Patient has the right to withhold or withdraw consent for telehealth at any time without affecting the right to the Patient’s future care, treatment, benefits, or programs for which he or she is otherwise entitled. The Patient understands that if others are present at Patient’s location during the Patient’s telehealth visit, the confidentiality of the Patient’s telehealth visit may be compromised.

The Patient understands the alternatives to telehealth, such as an in-person encounter, as they have been explained, and in choosing to participate in a telehealth visit understands that some parts of the exam may require physical testing to be performed at another location at the direction of the Practice.

THE PATIENT UNDERSTANDS THE PATIENT WILL BE RESPONSIBLE FOR PAYMENT. THE PRACTICE DOES NOT ACCEPT INSURANCE. ALL OUT-OF-POCKET EXPENSES ASSOCIATED WITH THE TELEHEALTH VISIT ARE DUE PRIOR TO THE TELEHEALTH VISIT.

The Patient understands that he or she must be physically located in the state of provider licensure during his or her telehealth consultation(s) and represents that the he or she is located in said state during the entirety of each telehealth visit. The Patient understands that if he or she is not physically located in the state of provider licensure, the Practice may decline to treat him or her via telehealth.

The Patient understands that the Practice’s healthcare professionals may prescribe medically appropriate medication to the Patient specifically to treat the Patient’s diagnosed condition, but there is no guarantee that the Patient will be prescribed medication. If medication is prescribed, the Patient, at all times, has the ability to request that his or her medication be fulfilled at the pharmacy provider of the Patient’s choice.

The Patient has been advised of all the potential risks, consequences and benefits of telehealth. The Patient has been afforded the opportunity to ask questions about the information presented on this form. All the Patient’s questions have been answered, and he or she understands the information contained herein.

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By entering my name below, I acknowledge that I have read and understand the terms of this consent, and I agree to receive services from the Practice via telehealth. I represent and warrant that I am authorized to provide this consent.

I can contact the Practice at help @ amsdoc. com / 832- 303- 1844 / 1032 E Brandon Blvd #2126, Brandon FL 33511 for a copy of this form.