Telehealth consent

Jeffrey Oppenheimer MD P.C. DBA Kosher Skinny Shots LLC (TM) — Telehealth Disclosure and Patient Consent

Telehealth involves the use of electronic communications to enable providers at different locations to share individual client information for the purpose of improving client care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Our system uses an asynchronous approach to the patient exam.

What is asynchronous telemedicine or telehealth?

Sometimes referred to as "store-and-forward", asynchronous telemedicine or telehealth is the process in which your medical or "clinical" information is collected and then sent electronically through a secure HIPAA platform for evaluation.

In other words, asynchronous telemedicine is when a patient completes a visit on their own time. The provider reviews the visit on their own time. Then the patient receives their diagnosis and treatment plans electronically. No scheduling. No appointments. No hassle.

This saves everyone time and ultimately creates an efficient system for you! You get your prescription faster without the need for multiple consultations. We however offer you more than telehealth — we offer you a coaching call to discuss all of your most pressing questions about the anticipated weight loss journey you should expect while using these easy-to-use medications for weight loss, and help you make those behavioral changes that keep you on track for the long term with ongoing health coaching as needed.

Expected Benefits

• Improved access to care by enabling a patient to remain in his/her provider's office (or at a remote site) while the providers obtain test results and consults from practitioners at distant/other sites.

• More efficient patient evaluation and management.

• Obtaining expertise of a distant specialist.

Possible Risks

There are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the providers and consultant(s);

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment;

• In very rare instances, security protocols could fail, causing a breach of privacy of personal health information;

• In rare cases, a lack of access to complete health records may result in interactions or allergic reactions or other judgment errors.

By signing this form, I understand the following:

1. I understand that the laws that protect privacy and the confidentiality of health information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other entities without my consent.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

3. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.

4. I understand that a variety of alternative methods of health care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.

5. I understand that telehealth may involve electronic communication of my personal health information to other practitioners who may be located in other areas, including out of state.

6. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.

7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

HIPAA Privacy and PHI Security Statement

We are committed to protecting your private health information in accordance with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and all applicable federal and state privacy laws.

All personal and medical information shared through our platform is considered Protected Health Information (PHI) and is safeguarded using reasonable administrative, technical, and physical security measures, including encryption, limited access, and secure storage.

Our staff and affiliated providers are trained to handle your data with confidentiality. However, no digital system can ever guarantee 100% security, and by using this telehealth platform, you acknowledge and accept this inherent risk.

PHI Disclaimer and Limitation of Liability

By participating in this telehealth service and submitting your information electronically, you acknowledge and agree that:

• Your PHI will be transmitted, stored, and processed using secure but third-party electronic systems, including forms, messaging, CRM, and pharmacy platforms.

• Despite best efforts, unauthorized access or data breaches may occur due to events outside our control, including cyberattacks or third-party vendor failures.

• In the event of a breach, we will comply with all notification requirements as required by law, including timely notice under HIPAA's Breach Notification Rule.

You release and hold harmless Thin Wellness Club LLC, Jeffrey Oppenheimer, MD P.C., DBA Kosher Skinny Shots and all affiliated entities, partners, and vendors from any and all liability resulting from the unintended disclosure, interception, or breach of your health information, unless caused by gross negligence or willful misconduct.

Patient Consent — Risk and Benefit Agreement

I have read and understand the information provided above regarding telehealth and the process that Jeffrey Oppenheimer MD P.C. DBA Kosher Skinny Shots LLC (TM) uses to help me on my weight loss journey. I hereby give my informed consent for the use of asynchronous telehealth in my full care. I understand that once I complete this medical screening intake to the best of my ability, a licensed medical practitioner will review the intake and make a decision to qualify me for the use of these weight loss injections.

I understand the risks and/or benefits of using either tirzepatide or semaglutide for weight loss. I also have reviewed my health assessment and have typed out all of my questions for the doctor and health coach to review before I get approved to use these medications.

I am aware that before my call the health coach may review this whole document with me one more time at length to ensure that I have no outstanding questions. This may be done via text, call or email in certain situations. I understand that there are a few things that the health coach will go over with me to help understand my personal goals for weight loss and health, and will answer all lifestyle questions related to this product(s). The health coach will help me understand the differences between these medications and how they work in my body to help me make the best decision as to which medication is best for my weight loss issues. Once I sign and agree to this health assessment I am also personally taking accountability for my own actions to help me get the best long term results possible.

I understand that Jeffrey Oppenheimer MD PC DBA Kosher Skinny Shots will prescribe compounded medications, which are not approved by the FDA as finished products, like brand-name drugs such as Ozempic, Wegovy, or Mounjaro/Zepbound. However, these compounded formulations are prepared by licensed U.S. compounding pharmacies using active pharmaceutical ingredients (APIs) that are FDA-approved for use in compounding under federal law. By proceeding with this process, I acknowledge this distinction, and I am electively choosing to use these compounded GLP-1 agonists, aka tirzepatide or semaglutide medications, based on the information presented to me here.

I also understand that while the risks are quite rare, some patients on semaglutide — and even tirzepatide, while less common than semaglutide and quite rare — have had acute gallbladder disease, acute kidney injury, allergic reactions, and a drop in blood sugar.

More commonly, some cases and clinical studies have indicated that people complained of nausea, vomiting, diarrhea, constipation, bloating, gas, and in some cases gastroparesis. The most common instances these complaints arise are especially with an increase or change in the dosage of these medications. So we will take the time to ensure you are medically cleared before we choose the medication for you and start you at the minimal effective dosage to prevent these potential side effects from occurring, and we are always here to monitor you every step of the way with a call, text, or email to our team.

Eye / NAION Risk Disclosure

I understand that recent studies (e.g., Medical News Today, June 2025, and a large-scale JAMA Ophthalmology study) have shown a potential increased risk of eye diseases, such as non-arteritic anterior ischemic optic neuropathy (NAION), in patients using GLP-1 medications, particularly semaglutide. According to the studies, semaglutide is the GLP-1 drug that has been most studied and flagged. I also understand that high-risk individuals may include (e.g., those with diabetic retinopathy, glaucoma, optic nerve disorders, or a history of stroke or vascular eye disease) and may be at increased risk of vision loss when taking GLP-1 receptor agonists.

In summary, I am being made aware here that according to the latest research there's no clear or consistent number that shows the exact risk of developing NAION (a rare eye condition) from taking GLP-1 medications. Some studies suggest the risk might be slightly higher, while others show no real difference compared to people not taking the medication. Overall, the chance of this happening appears to be very low — less than 1 in 1,000 people. By continuing, I confirm that after reading this and based on my current and past medical history when asked about eye and vision disorders, my risk is low since I marked off no next to the question about eye conditions. I attest that I understand these precautions and have been informed of this potential risk.

Patient Acknowledgement & Informed Choice for Customized Compounded GLP-1 Therapy

By signing below, I understand, acknowledge, and expressly consent to the following regarding my customized GLP-1 therapy prescribed by Dr. Jeffrey Oppenheimer MD PC DBA Kosher Skinny Shots and Jeffrey Oppenheimer MD P.C.:

The Basis of My Choice: I have clearly communicated my desire to avoid or minimize common and disruptive side effects associated with GLP-1 medications (such as nausea, vomiting, delayed gastric emptying, diarrhea, constipation, fatigue, or low energy), as indicated by my prior responses on the "Optimizing Your GLP-1 Therapy" section of my health assessment. I understand that Jeffrey Oppenheimer MD PC, the physician of record, has determined that a custom-compounded GLP-1 formulation is the most appropriate choice for my unique medical and treatment needs, given my stated preferences and/or documented intolerances to commercially available options. I understand that my customized formulation may include Methylcobalamin (B12) or Niacinamide (B3), known as "additional components" in this whole document. I confirm that by electively opting for these "additional components", I potentially allow myself to achieve a better treatment experience by minimizing or avoiding unwanted side effects. My Prior GLP-1 Therapy Tolerance Assessment may be used as the clinical rationale for determining the "additional components" that Jeffrey Oppenheimer MD clinically chooses to best suit my GLP-1 therapy. A Clinical Difference Statement on my prescription at the pharmacy will explain the rationale for adding either Methylcobalamin (B12) or Niacinamide (B3) to my GLP-1 agonist medication.

Understanding of Risks and Benefits: I have had the opportunity to discuss the potential benefits and risks of this customized compounded GLP-1 therapy, specifically the transdermal delivery method, with one of the health coaches who are here to provide readily available and curated public information about how the compounding process works. I understand that compounding pharmacists are regulated and trained to create customized medications by combining, mixing, or altering ingredients to meet specific patient needs that are NOT commercially available. I understand that they tailor specific dosages and formulations to make it easier to administer the drug when commercially available products may not be available in that form. This process is often used when a patient needs a dosage that is not commercially available. I am aware that compounding pharmacies are not regulated by the FDA, yet they use FDA-approved ingredients and may be regularly inspected by the FDA for safety and quality. These compounding pharmacies are regulated by the state boards of pharmacy. I am free to read blogs, listen to podcasts, read whitepapers and published articles, view television and videos, and even ask my own family physician. I am aware that health coaches are not medical professionals and only act as another source of guidance on helping me better understand the mechanism of GLP-1 agonists and unique lifestyle changes I can make to improve my overall health and wellbeing while using the GLP-1 agonists described here. I fully understand that, like all prescriptive medications, potential side effects may arise, and individual results may vary.

My Consent: I have read and understand this acknowledgement and consent. All my questions have been answered to my satisfaction. I voluntarily agree to proceed with the customized compounded GLP-1 therapy as prescribed by Jeffrey Oppenheimer MD PC DBA Kosher Skinny Shots LLC.

I have decided, based on the evidence and readily available public health information about GLP-1 agonists, that the benefits OUTWEIGH the risks of using these medications, and I am willing to start today.

Now that I have decided to proceed — Hydration, Protein & Diet Commitments

I understand that these shots will not just turn off my hunger signals in my brain and curb or shut my appetite significantly — the shot will also turn off my thirst signals.

1. I agree that I will make every effort to drink. I must drink at least 8 cups (64 ounces) of liquids a day. Water, no-sugar juice, milk, seltzer, soup, and some non-sugary sports drinks all count as good sources of hydration since they don't have caffeine. Tea and coffee are also liquid but can dehydrate me. I will attempt to carry around a large bottle of water to force myself to drink all day. Fruits like oranges and grapefruit, and vegetables like cucumber, tomato, and lettuce, have water in them to help add to my hydration.

2. I agree that I will make every effort to push in protein with my meals. I must attempt to eat a higher portion of protein from animal protein per day (if I don't eat animal protein I can get protein in vegan sources like plant-based products as well). This will all be discussed on my coaching call to determine what combinations of foods are high in protein and low in calories so I retain my muscle mass while losing my fat mass on these injections, as the medical research has proven that more protein builds muscle and burns excess fat and also helps me keep off the pounds later.

3. I agree that I will make every effort to cut deep-fried foods from my daily diet. I must try to cut out "deep fried" foods because they will stop my body from losing and breaking down my visceral or "old fat" and may slow down my overall weight loss. Deep-fried foods won't let my liver process the fat that the shots are helping my body break down. Examples are fried chicken, doughnuts, or French-fried potatoes.

Final Release

By signing this document, I voluntarily and knowingly release, discharge, and fully indemnify Jeffrey Oppenheimer, MD P.C., DBA Kosher Skinny Shots LLC, Thin Wellness Club LLC, and all affiliated physicians, health coaches, employees, advisors, brands, partners, managers, and associated entities from any and all claims, liabilities, or legal actions arising from or related to my use of these medications in any and all custom formulations prescribed to me. I am making this choice of my own free will, based on the information presented to me, and I accept full personal responsibility for my health and treatment outcomes under this telehealth model. I understand that I am always encouraged to seek in-person medical care, including a physical examination, lab work, or diagnostic imaging at any time, through a medical provider of my choosing, if I have concerns or wish to further evaluate my health status. I understand and agree that telehealth is not a replacement for a physical examination by a licensed medical physician or licensed clinical practitioner.

My signature is my agreement to the whole disclosure. I also answered all my medical history to the best of my knowledge and typed my personal health questions for the doctor's review.

Electronic Signatures: my signature shall be considered official as my original signature, timestamped in this system, and this will submit my form for processing.