Please read this document carefully. Your signature confirms your understanding and agreement.
WildBerryMD provides elective, wellness-based Telehealth services to individuals 18 years or older who are physically located in Arizona at the time of service. These services may include weight management, hormone therapy, thyroid optimization, nutritional support, and other elective wellness programs designed to support overall health and lifestyle goals.
1. Nature of Telehealth
Telehealth is the use of telecommunications and digital technology to provide health-related services and information remotely.
At WildBerryMD, Telehealth services are delivered using secure video conferencing platforms, telephone, encrypted email, online forms, and digital program materials. These allow you to receive wellness consultations, medical advice, and treatment plans without the need for in-person visits.
2. Scope of Services
WildBerryMD’s Telehealth services are limited to elective, wellness-based programs, including but not limited to:
- Medical weight loss
- Hormone and thyroid optimization
- Cravings and appetite management
- Metabolic and energy support
- Nutritional and lifestyle guidance
- Supplements
I acknowledge and agree that WildBerryMD and its affiliated healthcare providers do not serve as my primary care provider, specialist provider, or replace any other providers I am seeing.
The services I receive at WildBerryMD are not a substitute for emergency services, primary care, specialist care, or any other providers involved in my medical management.
I understand WildBerryMD highly recommends maintaining routine and preventive care, including physicals, OBGYN exams (for women), labs, diagnostic imaging, chronic condition care, and ongoing treatment by my PCP and specialists.
3. Risks and Benefits of Telehealth
Benefits may include convenience, timely access to care, and reduced travel.
By consenting to Telehealth, I understand that risks may include:
- Technology failures or interruptions
- Lack of physical examination
- Limitations in diagnosis and treatment compared to in-person visits
- Potential for miscommunication due to digital format
I understand that I can choose in-person care with another provider at any time and will notify WildBerryMD as a courtesy.
4. HIPAA Notice and Privacy Practices
WildBerryMD complies with the Health Insurance Portability and Accountability Act (HIPAA) and takes all reasonable precautions to protect the privacy and confidentiality of your health information.
- WildBerryMD uses secure, encrypted, HIPAA-compliant platforms.
- HIPAA-compliant third-party vendors may be used for scheduling, video conferencing, and communication.
- I consent to receive program-related communication via email and SMS.
- I may request a copy of WildBerryMD’s HIPAA Notice of Privacy Practices at any time.
5. Patient Responsibilities
I agree to:
- Provide accurate and updated health information.
- Inform my PCP, specialists, or surgeons of treatments I receive at WildBerryMD.
- Request record sharing if needed for continuity of care.
- Attend Telehealth appointments from a private, secure setting using a reliable internet connection.
- Obtain medical clearance from existing providers when appropriate.
- Follow recommended treatment plans and make necessary lifestyle changes.
- Not record or screenshot Telehealth sessions without written consent.
I understand that wellness and weight loss results vary by individual and are not guaranteed.
6. Financial Responsibility, Payments, and Refunds
- All services are self-pay.
- I am responsible for full payment at the time of service.
- All payments are non-refundable, including consultations, programs, medications, and follow-ups.
- Once a medication—especially compounded—has been ordered, it cannot be returned or refunded.
- Processing and shipping may take 7–12 business days. Delays may occur due to factors outside of WildBerryMD’s control, and I agree not to hold them liable for these.
7. Cancellation and Rescheduling Policy
- Appointments must be canceled or rescheduled with at least 24 hours’ notice.
- Missed appointments or cancellations with less than 24 hours’ notice may result in a $75 fee.
- Repeated no-shows may result in dismissal from the program.
8. Indemnity and Release of Liability
To the fullest extent permitted under Arizona law, I agree to release, defend, indemnify, and hold harmless WildBerryMD, its providers, employees, contractors, and affiliates from any and all claims, damages, or legal actions arising out of:
- My voluntary participation in Telehealth services
- The use or effects of off-label, compounded, or non-FDA-approved medications
- My failure to provide accurate medical history
- Any side effects, lack of results, or dissatisfaction with care
- Delays in pharmacy services, shipping, or communication
This does not apply to gross negligence or willful misconduct as defined by Arizona law.
I understand WildBerryMD does not act as my primary care provider, specialist, or replace other medical providers. I am responsible for notifying and coordinating care with my existing providers.
9. Nature of Services and No Guarantee of Results
I understand that the services offered by WildBerryMD are elective, wellness-based, and optional, and are not medically required. These services are intended to support lifestyle and wellness goals and are not intended to diagnose, treat, cure, or prevent any disease or medical condition.
I acknowledge that:
- No guarantees, warranties, or assurances have been made regarding the results, effectiveness, or duration of any treatment, program, or outcome.
- Individual results will vary and depend on many factors, including my adherence to the treatment plan, underlying health conditions, and lifestyle choices.
- Some therapies may involve the off-label use of medications or use of compounded products not reviewed or approved by the FDA for weight loss or hormone therapy.
- Participation in any service or program is entirely voluntary, and I may stop at any time after consulting with a WildBerryMD provider.
I understand that choosing these services does not imply a medical necessity and that they may not be recognized or endorsed by all medical professionals or health systems.
10. Nature of Services and No Guarantee of Results
I understand that the services offered by WildBerryMD are elective, wellness-based, and optional, and are not medically required. These services are intended to support lifestyle and wellness goals and are not intended to diagnose, treat, cure, or prevent any disease or medical condition.
I acknowledge that:
- No guarantees, warranties, or assurances have been made regarding the results, effectiveness, or duration of any treatment, program, or outcome.
- Individual results will vary and depend on many factors, including my adherence to the treatment plan, underlying health conditions, and lifestyle choices.
- Some therapies may involve the off-label use of medications or use of compounded products not reviewed or approved by the FDA for weight loss or hormone therapy.
- Participation in any service or program is entirely voluntary, and I may stop at any time after consulting with a WildBerryMD provider.
I understand that choosing these services does not imply a medical necessity and that they may not be recognized or endorsed by all medical professionals or health systems
11. Acknowledgment and Informed Consent
I have read, understand, and voluntarily agree to all terms in this Telehealth Informed Consent, Indemnity, and Arbitration Agreement.
I have had the opportunity to ask questions and receive answers to my satisfaction.
I understand that this consent may be revoked in writing at any time, though it does not affect care already provided.
I understand WildBerryMD may discontinue services at its sole discretion if I am non-compliant, disrespectful, or if my care needs fall outside its scope.
By signing electronically, I agree that my electronic signature is legally equivalent to my manual signature for this agreement.
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