Good Hearts Health: Consent for Consultation and Treatment

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Good Hearts Health: Consent for Consultation and Treatment

General Consent for Evaluation and Treatment for Patients of Good Hearts Health.

  • TO THE PATIENT: This consent form is simply to obtain your permission to perform the evaluation necessary to identify any condition that might require an appropriate treatment and/or procedure as part of your plan of care. You have the right to be informed about any condition identified and the options for recommended surgical, medical or diagnostic procedure to be used. You may then decide whether or not to undergo any suggested treatment or procedure, after being informed of the potential benefits and risks involved. This consent provides us with your permission to perform reasonable and necessary medical interview, examinations, testing and treatment.
  • By signing below, you are indicating that you understand that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended, along with potential risks and benefits. The consent will remain fully effective until it is revoked in writing. You have the right at any time to ask additional questions or to discontinue or decline services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.
  • I voluntarily request a physician, or the designees as deemed necessary, to perform reasonable and necessary medical interview, examination, testing and treatment for the condition which has brought me to seek care at this practice or one that has been identified. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
  • For Telemedicine Consults and Prescriptions: I certify that all of the information I have provided at the time of my telemedicine consult is accurate to the best of my knowledge including all listed medication allergies and medications I am currently taking. I also understand that there are potential side effects and adverse reactions to any prescription medication and I do not hold Good Hearts Health responsible for any of the known adverse reactions to the medications prescribed. I have been given the opportunity to ask questions regarding the effects and potential side effects of the medications prescribed and understand the risks associated with taking any prescription medication. I certify that I will take the medication prescribed to me as directed and will not modify the dose or frequency of the medication without direction by my physician.
  • For Semaglutide+ and Tirzepatide+ Therapy: I understand that the medication provided to me by Good Hearts Health is a compounded medication and I have been given the opportunity to ask all relevant questions regarding the benefits and risks associated with using compounded medications. I also understand that while Wegovy (Semaglutide) is FDA approved for treatment of weight loss in obesity, it is not FDA approved for weight loss in non obese patients. Mounjaro (Tirzapetide) is not currently FDA approved for treatment of weight loss. I also understand that compounded medications containing these drugs are not currently FDA approved despite their widespread use.
  • I have been given the opportunity to ask all questions regarding potential side effects and contraindications to taking Semaglutide+ and Tirzepatide + Therapy. I have also reviewed the list of potential side effects and contraindications available to review at any time on Good Hearts Health, LLC's website. I understand there are inherent risks in taking any medication and I consent to treatment with the above therapy despite any potential risks or side effects. I do not hold Good Hearts Health, LLC liable for any side effects associated with the prescribed medication.
  • Refund Policy: By signing below I certify that I have read and agree to the refund policy outlined on Good Hearts Health, LLC’s website ( under the FAQ section. Refunds will only be issued for canceled tests prior to specimen collection

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