Telehealth Informed Consent

Last Updated: April 2026

Please read and acknowledge each section before proceeding.

⚠ Attorney Review Notice: This Informed Consent form is provided as a template and should be reviewed by a licensed healthcare attorney before deployment. State telehealth consent requirements vary, and this form should be tailored to reflect applicable state law and the specific services offered.

🚨 EMERGENCY NOTICE: If you are experiencing a medical emergency, call 911 or go to your nearest emergency room immediately. Do not use this platform for emergencies. Telehealth is NOT appropriate for life-threatening conditions.

Consent Progress

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1. Nature of Telehealth Services

Telehealth involves the delivery of healthcare services using electronic communications, information technology, and other means between a healthcare practitioner and a patient who are not in the same physical location. AvataCore provides a technology and care coordination platform — clinical services are provided by independent licensed healthcare providers through the OpenLoop Health provider network.

Telehealth services through AvataCore may include: asynchronous review of health intake forms and questionnaires, secure patient-provider messaging, clinical evaluation for GLP-1 medication eligibility, prescription issuance (when clinically appropriate), and ongoing care check-ins. All consultations are conducted via HIPAA-compliant digital platforms.

Provider Qualifications:All healthcare providers accessible through AvataCore's platform are independent licensed professionals (physicians, nurse practitioners, or physician assistants) who are licensed to practice in your state of residence. Providers are credentialed through OpenLoop Health's provider network. AvataCore does not employ these providers; they exercise independent clinical judgment.

As with all medical care, there are potential benefits and risks associated with telehealth. Your provider will use professional judgment to determine whether telehealth is appropriate for your specific situation.

I understand the nature of telehealth services and that clinical care is provided by independent licensed healthcare providers, not by AvataCore. I consent to receiving care through AvataCore's telehealth coordination platform.

2. Benefits, Risks & Limitations of Telehealth

Potential Benefits:

Convenient access to licensed healthcare providers from your home or any private location
Reduced time and cost compared to traditional in-person clinic visits
Faster access to treatment with reduced wait times
Privacy of receiving care without visiting a clinic
Ongoing access to your provider team through secure messaging

Potential Risks & Limitations:

Telehealth has inherent limitations compared to in-person care — your provider cannot physically examine you
Certain medical conditions may require in-person evaluation and cannot be safely managed via telehealth
Without physical examination, some conditions may be difficult to detect or assess accurately
Technical failures (internet outages, software issues, device problems) may delay or interrupt your care
Information transmitted electronically may, despite robust safeguards, be intercepted by unauthorized parties
A prescription may not be issued if your provider determines telehealth is not appropriate for your situation

Alternative Treatments Available:

GLP-1 medications are one option for weight management. Alternatives include: in-person consultations with an endocrinologist or bariatric physician; FDA-approved brand-name GLP-1 medications (Ozempic®, Wegovy®, Mounjaro®, Zepbound®) through traditional healthcare channels; medically supervised diet and exercise programs; behavioral health interventions; and bariatric surgery for eligible candidates. You should discuss all options with your primary care provider.

I have read and understand the benefits, risks, and limitations of telehealth services as described above. I understand that alternative treatments are available and that I may seek in-person care at any time.

3. Patient Responsibilities

To receive safe and effective telehealth care, I understand and agree to the following responsibilities:

Accurate Health Information: I will provide complete, accurate, and honest health information including all current medications (prescription and over-the-counter), supplements, allergies, medical conditions, surgeries, and relevant family history. I understand that providing false or incomplete information could result in inappropriate care and/or immediate termination of services.
Follow-Up with Primary Care Provider (PCP): I understand that telehealth through AvataCore does not replace a comprehensive relationship with a primary care provider. I agree to maintain regular care with a PCP and to inform my PCP of all treatments I receive through AvataCore.
Reporting Changes: I will promptly notify my provider through the patient portal of any new symptoms, side effects, medication changes, or significant health changes that occur during treatment.
Safe Environment: I will participate in telehealth visits from a private, safe location where I can communicate freely and confidentially.
Medication Compliance: I will take all prescribed medications exactly as directed, store them according to instructions, and not share them with any other person.
Technology: I am responsible for having a compatible device, stable internet connection, and functional camera/microphone for video consultations when required.

I understand and accept my responsibilities as a telehealth patient, including providing accurate health information, following up with my primary care provider, and promptly reporting any health changes or adverse effects.

4. Emergency Situations & Limitations of Care

🚨 IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL 911 OR GO TO YOUR NEAREST EMERGENCY ROOM IMMEDIATELY. DO NOT CONTACT THIS PLATFORM DURING A MEDICAL EMERGENCY.

Signs of a medical emergency that require immediate in-person care include but are not limited to:

Chest pain, pressure, or tightness
Difficulty breathing or shortness of breath
Signs of stroke (face drooping, arm weakness, speech difficulty)
Severe allergic reaction or anaphylaxis
Severe abdominal pain
Loss of consciousness or altered mental status
Signs of pancreatitis (severe persistent stomach pain radiating to the back)
Thoughts of suicide or self-harm — contact the 988 Suicide & Crisis Lifeline by calling or texting 988

AvataCore's telehealth services are not equipped to handle medical emergencies. Our providers cannot dispatch emergency services. Response times through our platform may not be immediate and are not appropriate for urgent or emergency situations.

I understand that AvataCore's telehealth platform is NOT for medical emergencies. I will call 911 or go to the nearest emergency room in any emergency. I will not rely on this platform for urgent or life-threatening situations.

5. Privacy, HIPAA & Data Use

AvataCore protects your health information in accordance with HIPAA, the HITECH Act, and applicable state privacy laws. All consultations and health data are transmitted using encrypted, HIPAA-compliant systems. AvataCore acts as a HIPAA Business Associate to the independent healthcare providers who serve you.

Your protected health information (PHI) will be shared with: (1) the independent licensed provider(s) evaluating you; (2) licensed compounding pharmacies necessary to fill your prescription; (3) other service providers under HIPAA Business Associate Agreements. Your PHI will not be sold, shared with advertisers, or used for non-treatment purposes.

Your Rights: You have the right to access your medical records, request corrections, request an accounting of disclosures, and receive a copy of this signed consent at any time. To make a records request, contact admin@avatacore.com.

Please review our full Privacy Policy for complete details on data collection, use, and your rights.

I consent to the collection, use, and sharing of my health information as described above and in AvataCore's Privacy Policy, in connection with receiving telehealth services. I understand my HIPAA rights including the right to access my records.

6. Medication Risks & Consent

Compounded Medications: GLP-1 medications (semaglutide, tirzepatide) provided through AvataCore are compounded by licensed 503B outsourcing facilities. Compounded medications are not individually FDA-approved, though the active pharmaceutical ingredients are FDA-recognized compounds. Compounded medications may differ in formulation, concentration, or delivery method from commercially available brand-name products.

Known Side Effects:

Common: Nausea, vomiting, diarrhea, constipation, decreased appetite, fatigue, injection site reactions, headache, dizziness
Less Common: Heartburn, burping, stomach pain, bloating
Rare but Serious: Pancreatitis (severe stomach pain), gallbladder problems (gallstones, cholecystitis), kidney injury (usually from dehydration), elevated heart rate, vision changes (diabetic retinopathy progression), suicidal ideation (rare; monitor and report)
Based on Animal Studies (Human Relevance Unknown): Thyroid C-cell tumors — GLP-1 medications are contraindicated in patients with personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)

Drug Interactions: GLP-1 medications may interact with oral medications, particularly those requiring rapid GI absorption (e.g., oral contraceptives, antibiotics). Disclose all medications and supplements to your provider.

No Outcome Guarantees: Individual results vary significantly. Weight loss outcomes are not guaranteed and depend on adherence, lifestyle factors, metabolism, and individual physiology. Clinical trials demonstrated average weight loss of 15–22%, but individual outcomes may be substantially higher or lower, including no meaningful weight loss.

Dosing & Safety: I agree to follow my prescribed dosing protocol exactly as directed, store medication as instructed (refrigeration requirements apply), and not share my medication with any other person. I will report adverse effects to my provider promptly.

I consent to receiving compounded GLP-1 medications as prescribed. I have read and understand the known side effects, risks, contraindications, and the fact that outcomes are not guaranteed. I agree to follow all medication instructions and report adverse effects promptly.

7. Medical Records & Information Access

All medical records created through your use of AvataCore's platform — including provider notes, intake questionnaires, and prescription records — are your health records. You have the following rights regarding your records:

Right to Access: You may request a copy of your complete medical records at any time by contacting admin@avatacore.com. We will provide records within 30 days of a written request.
Right to Correction: You may request that inaccurate information in your records be corrected.
Right to Share: You may authorize us to share your records with any third party (such as your primary care provider) by submitting a written authorization.
Right to Restrict: You may request restrictions on certain uses or disclosures of your records, subject to applicable law.

Records are retained for a minimum of 7 years from last date of service, consistent with HIPAA and applicable state medical records laws. Records are stored on HIPAA-compliant, encrypted infrastructure.

Continuity of Care: With your permission, we can share your treatment records with your primary care provider to ensure continuity of care. We strongly encourage this practice for your overall health safety.

I understand my rights to access, correct, and share my medical records. I authorize AvataCore and the independent providers on its platform to create and maintain medical records in connection with my telehealth care, and to share those records with other treating providers as needed for my care.

8. Subscription, Auto-Renewal & Right to Withdraw

Auto-Renewal: My subscription will automatically renew at the end of each billing period (monthly, quarterly, or annual) at the then-current rate. I authorize AvataCore to charge my payment method on file on a recurring basis until I cancel.

Cancellation: I may cancel my subscription at any time through the patient portal or by emailing admin@avatacore.com. Cancellation takes effect at the end of my current billing period. No partial-period refunds are issued except as described in the Terms of Service.

Right to Withdraw Consent: I understand that I have the right to withdraw this telehealth consent at any time, without penalty. Withdrawal of consent means I am discontinuing telehealth services. Withdrawal does not affect care I received prior to withdrawal, and it does not prevent me from seeking traditional in-person care. To withdraw consent, I should contact admin@avatacore.com.

Refunds: If a provider determines I am ineligible for GLP-1 therapy after my initial intake, I will receive a full refund. Subscription fees are generally non-refundable once medication has been dispensed. Full details are in the Terms of Service.

I understand the subscription auto-renewal and cancellation terms. I understand that I have the right to withdraw this telehealth consent at any time without penalty by contacting AvataCore.

Your Rights as a Telehealth Patient

✓You have the right to refuse or withdraw this consent at any time without penalty or impact on future care
✓You have the right to access your complete medical records within 30 days of a written request
✓You have the right to request a second opinion from another provider at any time
✓You have the right to be informed of all treatment options, including non-telehealth alternatives
✓You have the right to know your provider's qualifications, licensure, and credentials
✓You have the right to receive clear explanations of your diagnosis, treatment plan, and medication instructions
✓You have the right to have your privacy protected in accordance with HIPAA and applicable state laws
✓You have the right to file a complaint with your state's medical board, nursing board, or the U.S. Department of Health and Human Services without retaliation
✓You have the right to seek immediate care from your local emergency room or primary care provider at any time

Electronic Signature & Acknowledgment

By clicking "I Consent — Submit" below, I acknowledge that:

I have read, understood, and agree to all sections of this Telehealth Informed Consent
I am at least 18 years of age and a US resident
I am providing this consent freely and voluntarily, without coercion
This electronic signature is legally binding and equivalent to a handwritten signature under applicable law
I have had the opportunity to ask questions and understand I may contact AvataCore for clarification at any time

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By clicking "I Consent" you are electronically signing this informed consent form. This electronic signature is legally binding. Date and time of consent will be recorded. A copy will be available in your patient portal.