Treatment Consent

Medical Consent

By participating in Clover Meds services—whether for weight management (GLP-1 or GLP-1/GIP) or adjunct therapies such as Nicotinamide Adenine Dinucleotide (NAD), and Testosterone Replacement Treatment (TRT) —you implicitly agree to the terms outlined in this medical consent. You acknowledge that you have read or have had read to you the below consent and understand the information presented.

The utilization of medications for weight management is recommended for individuals with a BMI of 30 or higher or a BMI of 25 or higher coupled with other medical conditions like high blood pressure, diabetes, or high cholesterol. Weight loss treatment, NAD therapy, and Testosterone Replacement Treatment are considered elective services, each with potential benefits and risks. By voluntarily participating in these treatments, you acknowledge your choice and agree to hold Clover Meds LLC and independent providers harmless for the use of such interventions.

You recognize that the extent of weight loss (and the effects of any adjunct treatments) varies among individuals and is influenced by personal dedication to diet, exercise, and consistency. No guarantees or specific claims about efficacy or a predetermined amount of weight loss are stated or implied. You acknowledge the significance of regular follow-ups with Clover Meds and your Primary Care Provider to track your progress during treatment. You understand that regular monitoring is crucial for safety and affirm you will adhere to the recommended follow-up schedule.

You hereby authorize Clover Meds and additional staff, including independent providers, to evaluate you for admission into the Clover Meds weight management program or other services offered, and treat you accordingly. You consent to continue regular care with your primary care provider for routine blood work. You certify that you are participating in this program of your free will and are competent to make your own medical decisions.

You have reviewed the mentioned risks and have determined that the benefits outweigh the possible risks associated with medically managed weight loss therapy, TRT, or NAD injections with Clover Meds. You release any claim in court or any type of complaint that could result from treatment with Clover Meds, their Independent Providers, and any other staff associated with Clover Meds, and will not hold liable any independent provider or staff of Clover Meds LLC.

You understand that treatment modalities utilized by Clover Meds and their independent providers might not be supported by scientific/medical literature and could be seen as experimental or based on anecdotal claims. Many medical providers (including endocrinologists, surgeons, family practice doctors, etc.) may view these types of treatments as not medically necessary. You also understand that the medications being utilized within Clover Meds’ medically managed weight loss program, TRT, or in NAD therapy are often compounded and do not undergo pre-market approval from the FDA. These treatments are prepared on a patient-specific basis rather than in large batches for the general public. As a result, there may be variations in dose, administration, side effects, and efficacy compared to commercially available brand-name drugs.

Telehealth Consent

Telehealth is a method of providing behavioral health services through audio-video interfaces, such as videoconferencing. The electronic systems used will incorporate network and software security protocols to ensure the confidentiality and integrity of client identification and imaging data.

Expected Benefits:

• Improved access to behavioral health care across distances and between programs.
• More efficient behavioral health care, including psychiatric evaluation and management.
• Access to the expertise of a distant specialist.
• Maintaining connections with established providers in other areas.

Possible Risks:

As with any medical procedure, there are potential risks associated with telehealth for behavioral health treatment. These risks include, but may not be limited to:

• Insufficient information transmission for appropriate medical decision-making.
• Delays in medical evaluation and treatment due to equipment deficiencies.
• Rare instances of security protocol failure leading to a breach of privacy.
• Lack of access to complete medical records potentially resulting in adverse outcomes.

By consenting to these forms, you understand the following:

• Privacy laws apply to telehealth, and no identifying information will be disclosed without my consent.
• You can withhold or withdraw consent to telehealth at any time without affecting future care.
• You have the right to inspect information obtained during a telehealth interaction.
• Alternative methods of behavioral health care are available, and you can choose them.
• It is in your best interest to inform all healthcare providers involved in my care.

Anticipated benefits from telehealth are expected, but results are not guaranteed.

Client Consent to the Use of Telehealth

You have read and understand the information provided regarding telehealth, have discussed it with your healthcare provider, and hereby give your informed consent for its use in Clover Meds services.

HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) establishes safeguards to ensure the confidentiality of your Protected Health Information (PHI). The implementation of HIPAA requirements officially commenced on April 14, 2003. This document serves as a simplified version, with a more comprehensive text available in the office and online.

Overview:

HIPAA imposes rules and restrictions on who may access or be informed of your PHI. These restrictions do not hinder the standard exchange of information necessary for office services. As a patient, you are entitled to specific rights and protections under HIPAA. We strive to balance these requirements with our commitment to providing quality professional service and care. Additional information is accessible from the U.S. Department of Health and Human Services website.

Adopted Policies:

1. Patient information will be kept confidential, shared only as necessary for service provision and administrative matters related to your care. This includes sharing information with healthcare providers, laboratories, and health insurance payers.
2. Patient files may be stored in open file racks without coding that identifies a patient's condition. Records may be temporarily left in administrative areas.
3. Appointment reminders may be sent via telephone, email, U.S. mail, or any convenient means requested by you. Other communications may inform you of policy or procedure changes.
4. The practice collaborates with vendors who may access PHI but must adhere to HIPAA confidentiality rules.
5. You agree to inspections of the office and document reviews, including PHI, by government agencies or insurance payers as part of their normal duties.
6. Concerns or complaints regarding privacy should be brought to the attention of the office manager or the doctor.
7. Your confidential information will not be used for marketing or advertising purposes.
8. Patients have access to their records in accordance with state and federal laws.
9. Provisions may be changed, added, deleted, or modified to better serve the needs of both the practice and the patient.
10. You have the right to request restrictions on the use of your PHI and changes in specific office policies related to your PHI. However, the practice is not obligated to alter internal policies to conform to such requests.

Consent

By continuing to use the services, you acknowledge and accept the terms outlined in the HIPAA INFORMATION FORM, including any subsequent changes in office policy. This consent remains in force from this time forward.

Financial Consent

You agree to keep a credit card on file for services, and any remaining balances will be paid in full. I authorize the release of necessary information for processing orders. I consent to auto-renewal of programs and automatic charges, with no refunds or exchanges.

Shipping Authorization

You understand that prescription medications will be dispensed in compliance with state and federal laws. You hold Clover Meds LLC harmless for any shipping delays or errors. You authorize the shipment of medication to the provided address and agree to the listed conditions.

Your continued use of the services constitutes your understanding and acceptance of the above terms.

Risks & Potential Side Effects

You acknowledge that no list of potential risks or side effects can be complete and agree to promptly report any concerning symptoms to your provider.

Testosterone Replacement Therapy (TRT)

You understand that Testosterone Replacement Therapy (TRT) involves the administration of exogenous testosterone and may result in side effects or adverse reactions, including but not limited to:

Common or Expected Effects

• Increased red blood cell count (elevated hemoglobin or hematocrit)
• Acne or oily skin
• Increased body hair growth
• Mild fluid retention or swelling
• Injection site discomfort or bruising
• Mood changes, including irritability or increased agitation

Hormonal & Reproductive Effects

• Suppression of endogenous testosterone production
• Testicular atrophy
• Decreased sperm production and potential infertility
• Changes in estradiol levels, which may contribute to:
  • Nipple sensitivity or tenderness
  • Fluid retention
  • Mood changes
  • Libido changes

Cardiovascular & Metabolic Considerations

• Changes in blood pressure
• Alterations in lipid profiles
• Increased blood viscosity associated with elevated hematocrit
• Potential increased risk of cardiovascular events in susceptible individuals

Other Potential Risks

• Acceleration of male-pattern hair loss in genetically predisposed individuals
• Worsening of untreated sleep apnea
• Prostate enlargement or changes in PSA requiring evaluation

This is not an exhaustive list of potential side effects. Individual responses vary, and additional adverse reactions may occur. You acknowledge that TRT requires ongoing monitoring, that individual responses vary, and that risks may increase if therapy is not properly monitored.

GLP-1 / GIP Therapy (Compounded Semaglutide and Tirzepatide)

You understand that GLP-1 receptor agonists and dual GLP-1/GIP therapies are used to support weight management and metabolic health and may cause side effects, including but not limited to:

Common Side Effects

• Nausea
• Vomiting
• Diarrhea
• Constipation
• Abdominal pain or cramping
• Decreased appetite
• Dyspepsia (indigestion)
• Fatigue
• Headache

Less Common but Potentially Serious Side Effects

• Dehydration due to persistent gastrointestinal symptoms
• Gallbladder disease (including gallstones or cholecystitis)
• Pancreatitis
• Hypoglycemia (especially when used with insulin or sulfonylureas)
• Acute kidney injury secondary to dehydration
• Worsening of diabetic retinopathy in patients with diabetes

Other Considerations

• Injection site reactions
• Increased heart rate
• Thyroid C-cell tumors observed in animal studies (human risk not established)

This is not an exhaustive list of potential side effects. Individual responses vary, and additional adverse reactions may occur. You acknowledge that compounded formulations may differ from FDA-approved products and that side effects and tolerability may vary between individuals.

Nicotinamide Adenine Dinucleotide (NAD+)

You acknowledge that NAD+ therapy is considered a wellness-oriented intervention and may cause side effects, including but not limited to:

Common Side Effects

• Flushing or warmth
• Nausea
• Headache
• Fatigue
• Lightheadedness
• Diarrhea or stomach discomfort

Less Common but Potentially Serious Side Effects

• Low blood pressure, particularly with higher doses or IV administration
• Palpitations or increased heart rate
• Histamine-type reactions (flushing, itching, rash)
• Sleep disturbances or insomnia
• Elevation of liver enzymes (rare)

This is not an exhaustive list of potential side effects. Individual responses vary, and additional adverse reactions may occur. You acknowledge that NAD+ therapy is not intended to diagnose, treat, cure, or prevent disease and that clinical evidence is still evolving.