Terms and Conditions

I understand that by signing this Health Care Informed Consent (“Consent”), I hereby freely give my informed consent to receive professional health care services from Infinity Health through a health care provider that treats me through a telehealth platform. Professional health care may include, without limitation, to review information I have provided or questions answered prior to a telehealth examination, to aid in providing a telehealth examination or consultation, to prescribe medication, and in the provisioning of any follow-up care, as needed. I understand Infinity Health is a telehealth medical practice; and that I may receive treatment from multiple third party providers, my protected health information may be shared among the providers in connection with my treatment and pursuant to the Practices’ privacy policies.

I consent to Infinity Health , accessing my medication history for treatment purposes through integrative electronic prescribing platforms and/or computer networks operated by providers of electronic prescribing services. I understand that I may withhold or withdraw my consent given hereunder which will not affect my ability to receive medical care.

I understand that the practice of medicine is not an exact science with any sort of guarantee of success or certainty in outcome and that diagnosis and treatment involves the risk of injury, misdiagnosis or other serious adverse event. I understand that there are risks and benefits when receiving any health care services and that the risks and benefits of such care will be explained to me and I will have the opportunity to ask my health care providers, questions about such risks and benefits. Services rendered by Infinity Health Providers do not and are not intended to replace your primary care medical services.

I acknowledge that no guarantees has or will be made to me regarding the result of a diagnosis or treatment provided to me by Infinity Health Provider.

I have disclosed all my known health conditions, allergies, and medications/supplements I am taking to Infinity Health Provider. I understand that certain treatment options that I may receive from or medications prescribed to me by Infinity Health Practice Provider can be dangerous and may result in medical care that is unnecessary if I have misrepresented my current health care condition and status. I have truthfully answered all questions from my health care provider including those about my health care condition and status.

I understand that the terms herein are contractual and not a mere recital and that by signing this agreement I agree to be bound by them. My signature is done under my own free will without coercion. The permissions granted herein shall begin on the date I agreed to this document and shall remain effective until terminated by me. I understand I have the right to withhold/withdraw my consent to these permissions at any time by submitting a request to do so via email to info@yourinfinityhealth.com.

I verify that I have read and understand all information contained in this Consent. I have had the opportunity to ask my Infinity Health Provider about anything I have not understood up to this point.

Health Care Informed Consent

Receipt of health care services from Infinity Health or any Infinity Health Provider and your use of the Infinity Health, LLC platform (the “Platform”) in connection with such health care services, constitutes an ongoing agreement to these Terms and Conditions of Payment (the “Terms and Conditions”). Capitalized terms used herein but not otherwise defined shall have the meaning given to such terms in the above Health Care Services Consent.

TERMS AND CONDITIONS OF PAYMENT

INSURANCE NOT ACCEPTED; YOUR RESPONSIBILITY FOR PAYMENT

I understand and acknowledge that Infinity Health from whom I receive care and the pharmacies that receive prescriptions from Infinity Health per the Platform, are not paid or reimbursed by managed care plans, Medicare, Medicaid, insurance providers, other government health care programs, or other third-party payors. Infinity Health does not accept insurance for its services. Except as otherwise explicitly stated herein, I will be billed directly and shall be personally responsible for payment, regardless of whether I am or will be reimbursed by a managed care plan or other third-party payer.

I agree to make timely payments for all health care, laboratory and pharmacy services that are provided to me. I understand by providing my payment information on the Platform, including but not limited to any credit card information or credit card hold information for future payments, I authorize Infinity Health, LLC to charge that information, or any other billing information it has on file for me for all amounts I owe relating to the items and/or services I receive or are scheduled to receive from the Infinity Health Provider providing my care, the laboratories and the pharmacies. I understand when I receive services, from Infinity Health, the cost of services (including medical care, laboratory, and prescription costs remitted directly to the laboratories and pharmacy on my behalf) is calculated ahead of time and the services are provided on an agreed upon basis, and that I will be billed for payment (even if I do not receive medical services or prescriptions in more than one month of the plan for which I am billed). I understand I have the choice to pay for my program cost upfront, in-full for the year (possibly at significant savings), or in monthly, or bi-monthly installments. I understand I am responsible, no matter when I cancel my services, for a prorated cost of my program even if I discontinue as a patient before completing the payment plan I’ve agreed to. I understand that the cost of services, including labs, medications, are final and not refundable. This is because the cost of treatment is for professional medical services (including any blood draws) which are fully rendered at point of care. I agree to not file any chargeback or credit card dispute for any amount billed from Infinity Health. I understand I will not be able to receive refunds for treatments and for medications, even if they are unused. Pharmacy rules prohibit the return of medications for reimbursement because medications are packaged for you and cannot be used for another patient. I understand that Infinity Health reserves the right to discontinue service if I am delinquent on any payments, for which I am responsible.

I understand and agree to provide a 30 day notice prior to stopping treatment or cancelling the services. I agree to have a final visit with an Infinity Health Provider, in order to safely discontinue use of the medications used in my treatment plan.

Any and all controversies, claims, or disputes arising out of, relating to, or resulting from these Terms and Conditions of Payment shall be subject to the arbitration provisions as set forth in the Terms & Conditions at www.yourinfinityhealth.com The provisions of these Terms and Conditions of Payment shall be severable, and if any provisions shall be prohibited by law, invalid, or unenforceable in whole or in part for any reason, the remaining provisions shall remain in full force and effect. The virtual consultation will be recorded by the provider to ensure protection and accuracy with HIPPA compliance and company policies.

The following information is provided to assist you with making an informed decision regarding the use of testosterone or other hormone therapies (which include but are not limited to testosterone cypionate, human chorionic gonadotropin (hCG), and anastrozole) which may be prescribed to you by an Infinity Health practitioner during the course of your treatments.

MISCELLANEOUS

Testosterone is a controlled medication with risks and benefits. Some potential benefits of testosterone & other hormone therapies include:

  • Improvement in energy

  • Improvement in sexual desire

  • Decrease in fatigue

  • Improvement in depressive symptoms

  • Increase in muscle mass;

  • and increase in bone density.

1.

Some known or potential risks of testosterone therapy & other hormone therapies, include (but are not limited to):

  • Worsening of cholesterol (in particular, “good” HDL);

  • increases in hematocrit (blood thickness);

  • breast tissue growth, swelling, or tenderness (gynecomastia);

  • elevated blood pressure;

  • water retention or swelling of arms or legs (edema);

  • blood clots in the legs, lungs, or brain;

  • increased risk of cardiovascular or cerebrovascular events;

  • lowering of sperm counts, possibly to the point of infertility;

  • acne and male pattern baldness;

  • reduced testicular size;

  • skin-to-skin transference to a partner or child (topical therapy);

  • skin irritation (topical therapy);

  • prostate cancer progression;

  • breast cancer progression;

  • liver dysfunction (oral therapy);

  • potential for abuse and dependence

2.

I understand that during the course of treatment I may or may not feel or develop any of these benefits, risks or discomforts and that should make these aware to my provider. I will have the opportunity to further discuss these potential benefits and risks with my provider.

Hormone therapy requires close monitoring and regular examinations during the course of treatment to ensure proper treatment; because of this I agree to have the appropriate laboratory testing and examinations completed as recommended.

I agree to proceed with treatment understanding that testosterone may cause an increase in prostate size and increase in PSA levels. Hormone therapy presents some risk of enhancing an existing current prostate cancer to grow more rapidly. For this reason, a prostate specific antigen blood test should be completed and passed before starting testosterone therapy and should be conducted at a minimum each year thereafter. If there is any possibility or inclination of possible prostate cancer, a follow-up with an ultrasound of the prostate gland may be required as well as a referral to a qualified specialist. While urinary symptoms typically improve with testosterone, rarely they may worsen, or worsen before then improving. Patients are required to undergo PSA blood testing and digital rectal exam (when clinically appropriate) on a routine basis as recommended by your provider. Testosterone restoration is contraindicated in patients undergoing active prostate cancer treatment or known prostate cancer (with some exceptions as agreed upon by patient and provider).

Testosterone therapy may increase one’s hemoglobin and hematocrit or thicken one’s blood. This problem can be diagnosed with a blood test. Thus, a complete blood count (Hemoglobin and Hematocrit) should be done at least annually.

Hormone therapy may require having a therapeutic phlebotomy performed if hematocrit levels increase to dangerous levels, I agree to follow these requirements if needed. I also understand that I will only be eligible to continue receiving the medication(s) if I am up to date with my examinations, laboratory work, and any necessary therapeutic tests or procedures, including therapeutic phlebotomies.

Aromatase Inhibitors (Anastrozole) utilization

Although the primary use for these types of medications is in the treatment of breast cancer in biological women, there is increasing use of this medication in men. Aging men, men who are overweight, those who are genetically predisposed, as well as others may have “estrogen excess” due to converting (aromatization) too much of their testosterone to estrogen. Human fat cells contain the enzyme “aromatase” which promotes this conversion. This estrogen conversion may decrease a man’s testosterone levels but also may cause estrogen to spike to higher levels; resulting in negative consequences and side effects; including gynecomastia (breast enlargement), hot flashes and night sweats, infertility, impotence, mood changes, prostate enlargement and increased risk for prostate cancer.

Peptides are small chains of amino acids that can have biological activity. They mostly occur naturally. Some are FDA approved for the treatment of certain diseases. Other peptides are also used clinically when prepared by registered compounding pharmacies complying with all state and federal laws. Peptides may be administered in various presentations, including but not limited to orally, intravenously, subcutaneously, intramuscularly and intranasally. As with any other drug or supplement, peptide therapies can have side effects, including but not limited to: nausea, vomiting, fever, injection site reactions (pain, rash, bleeding), Allergies, including life threatening allergies, and any additional side effects not listed.