Nationwide Telehealth + Local In-Clinic Services

This Medical Weight Loss Agreement (“Agreement”) outlines the terms, conditions, responsibilities, and obligations governing participation in the PharmXHealthOne Medical Weight Loss Program. By enrolling in the program, completing intake forms, or signing below, the Patient (“I,” “me,” or “my”) agrees to the following:

 

1. Program Overview

PharmXHealthOne provides medically supervised weight loss services, which may include:

• FDA-approved or compounded weight loss medications (including Semaglutide, Tirzepatide, or others)

• Nutrition, lifestyle, and behavioral counseling

• Medical monitoring through telehealth or in-person visits

• Optional peptide, hormone optimization, and functional medicine support

PharmXHealthOne reserves the right to modify program features at any time to maintain clinical safety, legal compliance, and operational integrity.

 

2. Telehealth Eligibility & State Regulations

I understand that PharmXHealthOne delivers services nationwide through licensed telehealth providers. Telehealth prescribing rules differ by state; therefore:

• Some medications may be restricted or unavailable in certain states

• Some states require an initial in-person physical exam

• Compounded medications may be regulated differently in my state

• PharmXHealthOne must comply with all federal and state medical board requirements

 

I acknowledge that PharmXHealthOne may be unable to prescribe certain treatments depending on my state of residence.

 

3. Medication Disclosure

I understand the following:

 

3.1. FDA-Approved Medications
PharmXHealthOne may prescribe branded FDA-approved medications such as Wegovy, Ozempic, Zepbound, or Mounjaro when medically appropriate and available.

 

3.2. Compounded Medications
If prescribed a compounded formulation of Semaglutide or Tirzepatide, I acknowledge:

• Compounded medications are not FDA-approved

• They are prepared by licensed 503A or 503B compounding pharmacies

• Formulations may differ from branded medications

 

3.3. Provider Discretion
The prescribing provider determines whether an FDA-approved or compounded medication is clinically appropriate.

 

4. Medical Risks & Limitations

I understand that weight loss medications may cause side effects, including but not limited to:

• Nausea, vomiting, constipation, diarrhea

• Decreased appetite

• Headaches, fatigue, or dizziness

• Abdominal discomfort

• Injection-site reactions

 

Serious risks may include:

• Pancreatitis

• Gallbladder disease

• Kidney complications

• Hypoglycemia

• Potential thyroid risks

 

I agree to immediately report concerning symptoms and may be instructed to discontinue medication.

 

5. Program Responsibilities

I agree to:

• Follow all medical instructions

• Attend required follow-up visits

• Complete required lab testing

• Disclose full and accurate medical information

• Not share my medication with others

• Notify PharmXHealthOne of changes in health status or medication use

 

Non-compliance may result in treatment delay, suspension, or discontinuation.

 

6. Pregnancy, Breastfeeding & Fertility

I understand:

• Weight loss medications are contraindicated during pregnancy or breastfeeding

• I must notify my provider immediately if I become pregnant or suspect pregnancy

• I may be required to stop medication immediately

 

7. Labs, Monitoring & Follow-Up

PharmXHealthOne may require initial and ongoing labs for clinical safety. Failure to complete labs within the requested timeframe may result in:

• Treatment suspension

• Medication pauses

• Program discontinuation

 

I am responsible for the cost of all labs unless otherwise stated.

 

8. No Guarantee of Results

I understand and agree that:

• PharmXHealthOne does not guarantee any specific amount of weight loss

• Results vary based on medical, behavioral, lifestyle, and metabolic factors

• Program success requires adherence to medication and lifestyle recommendations

 

Marketing testimonials or examples are not guarantees of individual outcomes.

 

9. In-Person vs. Nationwide Treatment Availability

I acknowledge:

• Weight loss medications and telehealth oversight are available nationwide

• Equipment-based treatments (laser, contouring, etc.) and IV therapies are available only in Florida or within a 20-mile radius of the Boynton Beach clinic

• Medication prescriptions may be available nationwide but infusions must occur locally

 

10. Medication Fulfillment

Prescription fulfillment may occur through:

• FDA-authorized pharmacies

• Licensed compounding pharmacies

• PharmXHealthOne’s partnered pharmacies

 

I acknowledge that:

• Pharmacy processing times vary

• Medication delays are not controlled by PharmXHealthOne

• Compounded medication fees are non-refundable after the pharmacy begins processing

 

11. Fees, Payments & Refund Policy

I agree to the following financial terms:

• All program fees, medication costs, follow-up visit charges, and labs are my responsibility

• Insurance may not cover weight loss services or compounded medications

• Payments are due at the time of service or at the time of ordering

• PharmXHealthOne does not guarantee insurance reimbursement

• Refunds are not issued for medications once they are ordered or processed

 

PharmXHealthOne reserves the right to modify pricing, fees, or program structure.

 

12. Termination of Program Participation

PharmXHealthOne may terminate or suspend my participation for:

• Safety concerns

• Non-compliance

• Failure to complete labs

• Providing inaccurate medical information

• Violation of state prescribing regulations

• Abusive or inappropriate conduct

 

I may voluntarily withdraw at any time, but previously paid fees may not be refundable.

 

13. Privacy, HIPAA & Confidentiality

PharmXHealthOne complies with all applicable federal and state privacy laws, including HIPAA.

I acknowledge that:

• My medical information will be handled securely

• Telehealth services may involve digital communication platforms

• I consent to the use of electronic communication for appointment reminders, treatment updates, and clinical communication

 

14. Telehealth Consent

By enrolling, I provide consent for:

• Remote diagnosis, evaluation, and treatment

• Use of electronic communication, video, audio, or messaging

• Storage of medical records in secure electronic systems

 

Telehealth services have inherent risks, including potential data interruption or unauthorized access. PharmXHealthOne uses HIPAA-compliant systems but cannot guarantee absolute cybersecurity.

 

15. Indemnification

I agree to hold harmless and indemnify PharmXHealthOne, its medical providers, staff, employees, and affiliates from:

• Claims arising from my failure to follow treatment instructions

• Misuse or mishandling of prescribed medications

• Failure to disclose full medical information

• Non-compliance with required follow-up care

 

16. Acknowledgment & Acceptance

By signing below, I confirm that:

• I have read and understand this Agreement

• My questions have been answered

• I voluntarily agree to participate in the Medical Weight Loss Program

• I understand the risks, responsibilities, and limitations of treatment

• I agree to comply with all program requirements

 

PATIENT SIGNATURE

Patient Name: __________________________________

Date of Birth: __________________________________

State of Residence: _______________________________

Signature: _______________________________________

Date: ___________________________________________

PROVIDER SIGNATURE

Provider Name: __________________________________

License Number / State: ____________________________

Signature: _______________________________________

Date: ___________________________________________