Telehealth Informed Consent

1. Purpose of this consent

This document explains how telehealth works through the Livozo platform, what its risks and benefits are, and what your rights are as a patient. Your signature at the bottom acknowledges that you have read and understood it and consent to receive care by telehealth from a clinician affiliated with {{PC_NAME}}.

2. Patient and provider identity

Before any visit, we will verify your identity using government-issued ID or other appropriate means. We will identify the clinician providing your care, the state(s) in which the clinician is licensed, and the clinician's credentials. You may decline to proceed with a specific clinician.

3. Nature of telehealth

Telehealth is the use of electronic communications (secure messaging, video, audio) to provide medical care when you and the clinician are in different locations. Visits through Livozo are primarily asynchronous— you submit an intake and the clinician reviews it and replies. Some visits may include synchronous video or phone. Telehealth does not include in-person physical examination.

4. Risks of telehealth

• Limited physical examination. Some conditions cannot be diagnosed or treated without an in-person exam.
• Technology limitations. Equipment may fail. Image or video quality may degrade. Messages may be delayed.
• Privacy and security. Although we use industry-standard safeguards, no electronic transmission is perfectly secure. There is a small risk that information could be intercepted by an unauthorized party.
• Possibility that telehealth is not appropriate for you. The clinician may determine that your condition requires in-person evaluation and may decline to treat you by telehealth.
• Medication risks. Any prescribed medication has potential side effects, interactions, and contraindications. Compounded medications carry additional risks described in section 11 below.

5. Benefits and alternatives

Benefits of telehealth include access to a licensed clinician without the need to travel, faster review, and reduced cost in some cases. Alternatives include seeking in-person care from a primary care physician, an endocrinologist, an obesity-medicine specialist, an urgent care center, or an emergency department. We encourage you to maintain a relationship with a primary care provider.

6. Your rights

• You may refuse telehealth and seek care in person without losing access to other services.
• You may withdraw consent at any time without affecting your right to future care.
• You may request that a different clinician provide your care, subject to availability.
• You may receive copies of your medical records and request amendments.
• You may file a complaint with us, with the state medical board, or with HHS without retaliation.

7. Emergency and follow-up care

Livozo does not provide emergency care. If you believe you are having a medical emergency, call 911 or go to the nearest emergency department. For non-emergency follow-up, you can send a secure message through the Livozo Platform. We aim to respond within one business day; complex questions may take longer. If symptoms are urgent and you cannot reach us, contact your primary care provider or an urgent care center.

8. Confidentiality

Information shared during a telehealth visit is protected by the same federal and state privacy laws that apply to in-person care, including HIPAA and (where applicable) CMIA. See the HIPAA Notice of Privacy Practices for details. Confidentiality may be limited in narrow circumstances permitted or required by law (e.g., mandatory reporting of abuse, court order).

9. No-recording statement

Visits will not be audio- or video-recorded by your clinician unless you are first notified and you agree. You may not record a visit without your clinician's consent.

10. Cost and insurance

Livozo is a cash-pay service. We do not bill commercial insurance, Medicare, or Medicaid. The price displayed at checkout is the price you pay for that order. HSA or FSA cards may be accepted at checkout depending on the payment method.

11. Supplemental consent: compounded GLP-1 medications

If your clinician determines that a compounded semaglutide or tirzepatide product is appropriate for you, you will be asked to provide a separate supplemental consent acknowledging the following:

• Compounded medications are not FDA-approved. The FDA does not review them for safety, effectiveness, or quality.
• Compounded semaglutide and tirzepatide are not generic equivalents of, and are not interchangeable with, Ozempic®, Wegovy®, Mounjaro®, or Zepbound®.
• Compounded versions of these medications may only be prescribed when there is a clinical reason that the FDA-approved drug is not appropriate for you (such as a documented allergy to an inactive ingredient or a dose that is not commercially available).
• Common side effects include nausea, vomiting, diarrhea, constipation, abdominal pain, and fatigue. Serious risks include pancreatitis, gallbladder disease, kidney problems, hypoglycemia (especially with other diabetes medications), and possible thyroid C-cell tumors (boxed warning for branded GLP-1 drugs).
• You will report side effects and any new medications or conditions to your Livozo clinician promptly.
• Refunds for compounded medication are limited per our Refund Policy. Federal law generally prohibits the return of dispensed prescription medication.

12. Withdrawing consent

You may withdraw this consent at any time by emailing [email protected]. Withdrawal applies prospectively; it does not affect care already provided. You may continue to use the Platform for non-clinical purposes after withdrawing.

13. Acknowledgment

By clicking “I consent” on the Platform, you acknowledge that you have read this consent, your questions (if any) have been answered, and you agree to receive care by telehealth.