Informed Consent for Telehealth Services

This consent form provides detailed information about how we care for you as our patient
Last updated August 3, 2025

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. Get 

Shapely provides telehealth services that may include patient consultations, group classes, treatment recommendations, the prescribing of clinically appropriate medications, remote patient monitoring (detailed later), 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.

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 theslf-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.

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 and consent to receiving remote patient monitoring services from Shapely as part of your health evaluation and treatment. 
  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.

Additional State-Specific Consents 

The following consents apply to patients accessing Shapely’s website for the purposes of participating in a telehealth consultation as required by the states listed below:

California: The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.​

Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov, email: licensecheck@mbc.ca.gov, or call (800) 633-2322.

Florida: I have received a copy of the Florida Weight Loss Consumer Bill of Rights, as set forth below: 

Warning: 

  • Rapid weight loss may cause serious health problems.  Rapid weight loss is weight loss of more than 1 ½ pounds to 2 pounds per week or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight-loss program. 
  • Consult your personal physician before starting any weight-loss program.
  • Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long-term weight loss.
  • Qualifications of your weight loss provider are available upon request.

You have a right to:

  1. Ask questions about the potential health risks of this program and its nutritional content, psychological support, and educational components. 
  2. Receive an itemized statement of the actual or estimated price of the weight-loss program, including extra products, services, supplements, examinations, and laboratory tests.
  3. Know the actual or estimated duration of the program.
  4. Know the name, address, and qualifications of the person who has reviewed and approved the weight loss program according to section 468.505(1)(j), Florida Statutes.
    I have been informed that if I want to check the licensing details for a provider I can visit the Florida Department of Health’s website, here. 

Texas: I have been informed of the following notice:
NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.  


AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us