Research Purposes Only. NOT FOR HUMAN CONSUMPTION
You have requested MyGLP1Store to arrange for a licensed physician (“Physician”) to review the health information you provide through our online platform (the “Platform”) to determine whether any MyGLP1Store products are medically appropriate for you. The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent for MyGLP1Store and its affiliated Providers to deliver care.
In this Consent, the terms “you” and “yours” refer to the person using the MyGLP1Store website or Platform. In the case of minors between 13 and 18 years old (or the higher age of majority under applicable state law), “you” refers to both the minor and the parent or guardian providing consent.
Please read the information below carefully. By clicking “I Agree,” using the Platform, or otherwise indicating your acceptance, you acknowledge that you understand and agree to the following:
Telehealth involves the use of electronic communication systems and technology to provide care when you and your Physician are not in the same physical location. Telehealth may be used for diagnosis, treatment, prescribing, patient education, and follow-up care via phone, electronic transmission of records, or other electronic communications, including messaging or email.
Potential Benefits of Telehealth:
Improved access to care
Increased efficiency of medical services
Access to care at convenient times and locations
Potential Risks of Telehealth:
Limited ability for in-person exams may affect care quality or diagnostic accuracy
May require seeking alternative care sources
Technology errors or malfunctions may impact timeliness, accuracy, or availability of care
Possible failures in technology, equipment, or security systems may result in loss of health information or breaches of privacy
The health care you receive through the Platform will be delivered via telehealth. By using the Platform or requesting a Physician Review, you consent to this method of care.
You understand that a Physician may determine at any time that telehealth is not medically appropriate, in which case you must discontinue using the Platform.
You may withdraw your consent to use telehealth at any time by providing written notice to MyGLP1Store. Withdrawal is effective upon receipt but does not affect care provided prior to withdrawal. Withdrawal does not affect other terms of this Consent. Note that neither the Physician nor MyGLP1Store provides in-person care, so care through the Platform will no longer be available after withdrawal.
The Platform is not for emergencies.
For medical emergencies, dial 911.
For mental health emergencies or suicidal thoughts, dial the 988 Suicide & Crisis Lifeline.
MyGLP1Store and its Physicians use software and network security protocols to protect your health information. Protected health information will not be released without your consent except as required by law. Communications from the Platform may contain your health information. You acknowledge that absolute security cannot be guaranteed on the Platform or your equipment.
There is no guarantee you will receive a prescription for a MyGLP1Store product.
No specific results are guaranteed from using the Platform or MyGLP1Store products.
You agree to provide complete and accurate information about yourself and your health. Inaccurate or incomplete information may pose health risks. The Physician relies solely on the information you provide through the Platform.
Fees paid to MyGLP1Store cover the cost of using the Platform, receiving a Physician Review, and any prescribed products. Neither MyGLP1Store nor the Physician will bill your insurance or third-party payors. You are responsible for any follow-up care.
If a product is prescribed, it will be sent to an affiliated pharmacy for dispensing and delivery to your provided address. You may select your pharmacy, but product availability cannot be guaranteed.
By clicking “I Agree” or using the Platform, you consent to sharing your protected health information with affiliated pharmacies, as described in MyGLP1Store’s Privacy Practices. Copies of your medical record are available upon request at farmacy@support.com.
For Physician concerns, contact the relevant medical licensing board.
For pharmacy-related concerns, contact the appropriate pharmacy licensing board.
