Medical Disclosure:
By enrolling in the Revive-ify Membership, I acknowledge that Revivify Wellness and its licensed providers offer telemedicine-based medical services focused on wellness, medical weight management, and related therapies. I understand that treatment plans may include prescription medications (including compounded or brand-name options), supplements, or peptides, when medically appropriate.
I understand that:
1. Services are not a substitute for in-person medical care or emergency treatment.
2. My provider may require recent labs or additional health information before prescribing medications.
3. Results are individual and cannot be guaranteed.
4. I am responsible for informing my provider of any changes in my medical history, medications, or health status.
Telehealth Consent:
I consent to receive medical care via telehealth, meaning I may be evaluated and treated through electronic communications. I understand the potential risks and limitations of telemedicine, and I agree to proceed with care in this format.
HIPAA & Privacy Consent:
I acknowledge that Revivify Wellness follows all federal and state laws governing the privacy and security of my health information (HIPAA). My personal health information will only be used for purposes of treatment, billing, and clinic operations. My information will not be shared without my written consent, except as required by law.
Membership & Billing Consent:
By submitting this form, I authorize Revivify Wellness and its payment processor (Stripe) to securely store my payment method and charge the monthly membership fee as outlined in the membership description. I understand that this membership renews automatically each month until I provide written notice of cancellation.