Informed Consent for Telehealth Services and Practice Policies

This consent form provides detailed information about how we care for you as our patient
Last updated Feb 18, 2026.

Services Provided

The purpose of this consent form is to provide patients (“patient,” “you,” or “your”) with information about Zaghi Medical Inc., doing business in New York as Zaghi Medical P.C. (“Shapely”) services and to obtain your informed consent concerning the treatment methods, risks, and limitations of using telehealth services. Services may be provided by Shapely or an affiliated third-party entity.

Shapely provides telehealth services that may include patient consultations, group classes, treatment recommendations, the prescribing of clinically appropriate medications, remote patient monitoring, and/or a referral to in-person care, as determined clinically appropriate (the “Services”). Services may be provided by licensed healthcare providers contracted with or employed by Shapely.

OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.  AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD CONTACT YOUR LOCAL PRIMARY CARE PROVIDER.

Telehealth Services

Telehealth services may involve the delivery of healthcare services to you by physicians, registered dietitians, physician assistants, nurse practitioners, and/or other health professionals (“Providers”) using the online platforms owned and operated by Shapely.

Shapely provides services via telehealth. Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and an individual who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, the following:

  • Electronic transmission of medical records, photo images, personal health information or other data;
  • Interactions via audio, video and/or data communications (such as messaging or email communications);
  • Use of output data from medical devices, sound and video files.
  • Prescription refill reminders (if applicable); and/or
  • Other electronic transmissions for the purpose of rendering clinical care to you.

Alternative methods of care may be available to you, such as in-person services, and you may choose an available alternative at any time. Always discuss alternative options with your Provider.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient information and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.  All the Services delivered to you through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

Benefits of Telehealth

  • Improved access to care by enabling you to remain in your preferred location while your Provider consults with you.  
  • Convenient access to follow-up care.  If you need to receive non-emergent follow-up care related to your treatment, please contact our Providers by directly sending a message through the patient’s user account. If you are unable to reach us through your user account, please call us (424) 600-8360, or by email at hello@getshapely.com
  • More efficient care evaluation and management. All patient communications transmitted via telehealth technologies (e.g. the patient app, our patient portal, email or telephone call) will be answered within one to two business days on average, and on the business day following weekends and holidays

Telehealth Limitations and Risks

The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.

As with any medical procedure, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

  • Insufficient transmission of information that does not allow for appropriate decision-making and diagnosis by the Provider;
  • Delays in diagnosis, consultation, and/or communication due to deficiencies or failures of equipment or systems;
  • In rare instances security protocols could fail resulting in a breach of privacy involving personal health information; or
  • Adverse results or reactions due to lack of access to complete medical records.
  • Telehealth is not appropriate if you need urgent medical attention.  Shapely telehealth services do not include a physical examination.  If it is determined that a physician examination is necessary, you may be referred to another provider.
  • In rare events, your Provider may determine that the transmitted information is of inadequate quality necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care provider.

Remote Patient Monitoring Services

  • Shapely may provide remote patient monitoring (“RPM”) services to support clinical decision-making. RPM is not used to identify or notify you of emergencies and is not monitored on a continuous or 24/7 basis. In a medical emergency, call 911 or go to the nearest emergency department.
  • While enrolled in RPM, you will use a loaned monitoring device (“RPM Device”) to collect and electronically transmit health information to your Provider. RPM information will be stored in your patient record, and all data will be stored securely in compliance with applicable law. As with any electronic system, there is a small risk of transmission issues or data security breaches.
  • You have the right to terminate Shapely’s RPM Services at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You can do this by contacting patient support services at (424) 600-8360 or emailing hello@getshapely.com.

Further, the RPM Services will be deemed terminated upon any of the following:

  1. You notify Shapely that you wish to terminate the RPM Services.
  2. Your treating Provider determines the RPM Services are no longer medically necessary.
  3. A period of 30 consecutive days occurs with fewer than 2 successfully transmitted readings to Shapely (this includes, but is not limited to, unresolved transmission interruptions caused by your failure to charge or use the RPM Device(s) correctly or from you taking any other actions or inactions that disrupt the accurate collection and/or transmission of Your Information).
  • While participating in Shapely’s RPM Services, you agree that you will not participate in RPM Services with any other provider. You understand that only one provider may provide and be paid for RPM Services during a 30-day period.  You agree that you will notify Shapely in writing if you elect to participate in RPM Services with another provider and will ensure Shapely’s RPM Services have terminated before you actively participate in services with another provider. If you participate in RPM Services with more than one provider, you will be financially responsible for Shapely’s full charges for the RPM Services provided to you.
  • In order to participate in the RPM Services, you may be provided third-party products and/or services. Shapely has made no representations or warranties regarding your use of, or interaction with, any third-party systems, software, hardware, or data. This applies even to third-party products and/or services that Shapely may recommend. You agree that Shapely is not responsible for any third-party products and/or services and you will look solely to such third parties for any claims relating to your use of such products and/or services, including claims concerning the accuracy, completeness or reliability of the data produced or transmitted by those products. You further agree that Shapely is not responsible for the security of Your Information stored by any third-party.
  • All RPM Devices are loaned equipment and remain the property of Shapely. When RPM participation ends for any reason, you agree to return the device within 14 days using prepaid return packaging provided by Shapely. If the device is not returned, or is lost, damaged, or unusable upon return, you agree to a $100 replacement fee per device.

Practice Policies

  1. Appointment cancellations: You must provide at least 24 hours’ notice to cancel or reschedule an appointment. Late cancellations or missed appointments may result in a $50 fee.
  2. Self-Pay Patients: Payment is due before your visit. Please make sure an active credit card is on file to avoid any delays in care.
  3. Insured Patients
    • Co-pays will be charged to your card on file on the day of your appointment.
    • Deductibles or coinsurance amounts are due within 14 days of your invoice and will be charged to your card unless paid before then.
    • Please let us know right away if your insurance changes. If we can’t bill your plan, you’ll be responsible for the self-pay rate.
    • If you have secondary insurance, please provide that information in advance. We’ll be happy to submit to your secondary plan, but you may still be responsible for any remaining balance.
  4. Medication purchases: All medication purchases—including compounded medications—are non-refundable. Due to the personalized nature of these prescriptions, they cannot be canceled, returned, or exchanged once ordered. This policy ensures the safety and integrity of your medications.
  5. Unpaid balances: If a payment remains unpaid for more than 21 days and you haven't contacted us, we will assume that you have chosen to discontinue care with Shapely. If you're experiencing financial hardship, please reach out as soon as possible to discuss available options.
  6. Contact: You can contact us at (424) 600-8360 or hello@getshapely.com with any questions or concerns you may have.

Medicare Acknowledgment

  • You acknowledge that Shapely is a Medicare participating provider and is also in network with several commercial insurance plans.
  • You authorize Shapely to bill Medicare and any commercial or secondary insurance for covered services provided to you, including telehealth visits, medical nutrition therapy, remote patient monitoring, and chronic care management
  • You acknowledge that only one Medicare practitioner can furnish and bill for chronic care management in a calendar month and that you have the right to stop these services at any time (effective the end of a calendar month).
  • As a practice, Shapely works to get medications approved by your insurance by assisting with prior authorizations. However, you expressly acknowledge and understand that Medicare and commercial insurances do not cover compounded weight loss medications, including semaglutide and tirzepatide, and that these medications will be considered an out of pocket expense.
  • You understand that treatment with medication is not required as part of your participation with Shapely, and you may decline at any time.

Patient Acknowledgment

BY SIGNING THIS CONSENT, YOU ATTEST TO AND UNDERSTAND THE FOLLOWING:

  1. You understand that prior to the telehealth visit, you have elected to be assigned to the next available Shapely Provider and have been given the Provider’s credentials.
  2. You understand that if you are experiencing a medical emergency, you will be directed to dial 911 immediately. The Provider is not able to connect you directly to any local emergency services.
  3. You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time without affecting your right to future care or treatment.
  4. You understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth which identifies you will be disclosed to researchers or other entities without your consent .
  5. You understand that you have the right to inspect all information obtained and recorded in the course of telehealth interaction and may receive copies of this information for a reasonable fee.
  6. You understand that Shapely will take steps to make sure that your health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of your personal health information to other health practitioners who may be located in other areas, including out of state. You understand that there is a risk of technical failures during the telehealth visit beyond the control of Shapely.  
  7. You understand that a variety of alternative methods of medical care may be available to you including in-person services, and that you may choose one or more of these at any time. Your Provider has explained the alternatives to my satisfaction.
  8. You understand that persons may be present during the telehealth visit other than your Provider who will be participating in, observing, or listening to your consultation with your Provider (e.g., in order to operate the telehealth technologies). If another person is present during the telehealth visit, you will be informed of the individual’s presence and his/her role prior to beginning any telehealth visit.
  9. You understand that SMS messages are not secured in accordance with the HIPAA security standards, and Shapely advises that you not share confidential information via text message. Shapely recommends that you use Shapely’s HIPAA-compliant secure messaging portal Healthie, which is available via both web and mobile applications. If you elect to communicate via text message, personal information including protected health information may be included.
  10. You understand that your Provider will explain your diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.  
  11. You understand that by creating a treatment plan for you, your Provider has reviewed your medical history and clinical information and, in your Provider’s professional assessment, has made the determination that the Provider is able to meet the same standard of care as if the health care services were provided in-person when using the selected telehealth technologies.
  12. You understand that it is necessary to provide your Provider with a complete, accurate, and current medical history.  You understand that you can log into your “Portal” via www.getshapely.com at any time to access, amend, or review your health information.
  13. You understand that there is no guarantee that you will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of your Provider.  If your Provider issues a prescription, you have the right to select the pharmacy of your choice.
  14. You understand that there is no guarantee that you will be treated by a Shapely Provider. The Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of your Provider, the provision of the Services is not medically or ethically appropriate.  
  15. You understand and agree that any prescriptions that you acquire from a Provider will be solely for your personal use. You agree to fully and carefully read all provided product information and labels and to contact a physician or pharmacist if you have any questions regarding any prescription.
  16. You understand that while losing weight generally has many health benefits, in rare circumstances medical recommendations related to weight loss may result in adverse effects, including nutritional deficiencies related to nutritional changes and musculoskeletal injury related to increased physical activity. In addition, prescription medications and other recommended treatments could also result in adverse events such as allergic reactions or side effects.
  17. You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.
  18. You understand and acknowledge Shapely's practice policies.
  19. You acknowledge that you have reviewed and agreed to the Recurring Payment Consent, which includes policies for recurring charges and cancellations.

By signing this document, you agree that you have been provided and reviewed the following notices:

State Specific Notices

Notice of Privacy Practices

Recurring Payment Consent