17940 Farmington Rd. Suite 130, Livonia, MI 48152
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CONSENT FOR LIMITED ONLINE WEIGHT LOSS TREATMENT AND
ACKNOWLEDGMENT OF LIMITED PHYSICIAN-PATIENT RELATIONSHIP
Weight Loss Services Specifically
Limited Nature of Relationship
THIS FORM MUST BE PLACED IN THE MEDICAL RECORD.
A COPY MAY BE GIVEN TO THE PATIENT.
*Company may not be the provider of medical services; medical treatment may be provided to Company users utilizing a separate entity or other Professionals who are medical professionals. **“Telehealth” means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers. ***Online prescriptions will only be issued when indicated and approved by a physician, and as permitted by law in your state.
17940 Farmington rd. suite 130 Livonia, MI 48152
Phone : +1 (734) 522-8590