Thank you for choosing Evercurrent for your wellness journey. This document outlines the risks, benefits, and procedures associated with telehealth services and the use of Glucagon-like Peptide-1 (GLP-1) receptor agonist medications.

1. Telemedicine Services

I understand that I am participating in a telehealth consultation with a licensed healthcare provider (MD, DO, NP, or PA).

Limitations: I understand that telehealth differs from in-person care. Because the provider is not physically present, the exam relies on my self-reported history, submitted pictures/videos, and/or virtual, real-time assessment.

Technology Issues: I understand that technical failures may occur, which could interrupt the visit or cause a delay in care.

In-Person Evaluation: If the provider determines my condition cannot be safely managed via telehealth, I may be referred for an in-person physical examination.

2. GLP-1 Medication Treatment (Semaglutide/Tirzepatide)

I am seeking treatment for weight management using compounded GLP-1 medications (such as Semaglutide or Tirzepatide).

Compounded vs. Brand Name: I understand that the medication prescribed is a compounded medication sourced from a 503A pharmacy. It is not a brand-name, FDA-approved product like Ozempic®, Wegovy®, or Zepbound®, although the active ingredient is the same.

Mechanism: I understand that these medications work by slowing gastric emptying, increasing satiety, and reducing appetite.

No Guarantees: I acknowledge that there are no guarantees for specific weight loss results.

3. Potential Risks and Side Effects

I understand that GLP-1 medication therapy carries risks. Known side effects include, but are not limited to:

Common: Nausea, vomiting, diarrhea, constipation, abdominal pain, headache, fatigue, indigestion, dizziness, belching, and injection site reactions.

Serious: While rare, potential serious risks include pancreatitis, hypoglycemia (low blood sugar), gallbladder issues, kidney issues, and allergic reactions.

Black Box Warning: I understand that GLP-1 medications carry a boxed warning for thyroid C-cell tumors. I have disclosed if I have a personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2), which are contraindications for this therapy.

4. Patient Responsibilities & Requirements

Disclosure: I have fully disclosed my medical history, including all allergies, past procedures, and current medications (including supplements and OTC drugs).

Pregnancy/Breastfeeding: I confirm I am not pregnant, not breastfeeding, and do not intend to become pregnant while on this medication.

Self-Administration: I have been trained on or understand how to self-administer subcutaneous injections.

Storage & Handling: I will keep the medication refrigerated and will not share needles or medication.

Adherence: I will follow the prescribed dosage and not deviate from the titration schedule / plan without consulting my provider.

5. Financial & Refund Policy

Payment: I am responsible for the full cost of the monthly subscription fee and medications. I understand these services are typically not covered by insurance.

No Refunds: I understand that once a prescription is sent to the pharmacy, it cannot be returned or refunded.

6. Consent to Treatment & Release of Liability

By signing below, I acknowledge that:

1. I have read this form or have had it read to me.

2. I understand the risks, benefits, and alternatives to GLP-1 medication and telehealth.

3. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction.

4. I voluntarily consent to treatment

5. I release Evercurrent and its providers from any liability related to the non-negligent administration of this treatment