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Houston Concierge Medicine (HCM) Consent To Treat

CONSENT TO TREAT, TELEHEALTH CONSENT, FINANCIAL RESPONSIBILITY & DISPUTE RESOLUTION AGREEMENT

Houston Concierge Medicine

Effective Date: May 12, 2026

CONSENT TO MEDICAL CARE & TREATMENT

I voluntarily consent to medical care, treatment, procedures, evaluations, diagnostic testing, telehealth services, and other healthcare services provided by Houston Concierge Medicine (“Practice”), including services performed by physicians, nurse practitioners, physician assistants, nurses, medical assistants, contractors, affiliates, or authorized healthcare personnel associated with the Practice.

I understand that I have the right to ask questions regarding any proposed treatment, procedure, medication, therapy, or diagnostic service and that I may refuse or withdraw consent for treatment at any time, except where emergency treatment or legal obligations require otherwise.

I acknowledge that no guarantees or warranties have been made regarding the outcome of any treatment, procedure, therapy, medication, or medical service.

SERVICES PROVIDED

I understand that services offered by Houston Concierge Medicine may include, but are not limited to:

  • Primary Care Services

  • Preventive & Wellness Care

  • Concierge Medicine Services

  • Telehealth & Telemedicine Services

  • COVID-19 Testing

  • Laboratory & Diagnostic Testing

  • Hormone Optimization & TRT

  • Peptide Therapy

  • Medical Weight Loss Services

  • IV Therapy & Injectable Therapies

  • Cosmetic & Aesthetic Treatments

  • Wellness Therapies

  • House Calls

  • Prescription Management Support

I acknowledge that the risks, benefits, alternatives, and limitations associated with recommended services have been explained to me and that I have had the opportunity to ask questions before proceeding with treatment.

TELEHEALTH & TELEMEDICINE CONSENT

I consent to receive healthcare services through telehealth and telemedicine technologies, including audio, video, electronic communications, remote monitoring, messaging systems, and other digital communication methods.

I understand that telehealth services may have limitations and risks, including but not limited to:

  • Technical failures or interruptions

  • Unauthorized access despite reasonable security safeguards

  • Delays in evaluation or treatment due to technology limitations

  • Reduced ability to perform comprehensive physical examinations

  • Miscommunication caused by electronic transmission issues

  • Risks associated with internet-based communications

I understand that no electronic communication system can be guaranteed to be completely secure.

I acknowledge that I am responsible for selecting a private and secure environment for telehealth appointments and for protecting my own device security and internet access.

I understand that telehealth services may not be appropriate for all medical conditions and that the Practice may determine that in-person evaluation or emergency care is necessary.

PATIENT DISCLOSURES & RESPONSIBILITIES

I certify that I have provided accurate and complete information regarding my:

  • Medical history

  • Current medications

  • Allergies

  • Symptoms

  • Prior diagnoses

  • Relevant health conditions

I understand that withholding or misrepresenting information may negatively impact diagnosis, treatment, outcomes, or patient safety.

I agree to promptly update the Practice regarding any changes to my health status, medications, or medical history.

CUSTOMIZED & OFF-LABEL THERAPIES

I understand that certain therapies, medications, compounded formulations, supplements, peptides, hormone therapies, wellness protocols, or customized treatments may be prescribed or recommended based on individualized medical judgment.

I further understand that some therapies may:

  • Be considered off-label

  • Not be FDA-approved for a particular use

  • Be compounded specifically for individualized treatment

  • Not have undergone extensive long-term studies

I voluntarily consent to such therapies after discussion with my healthcare provider and understand that no guarantee of effectiveness or outcome has been made.

COVID-19 & COMMUNICABLE ILLNESS ACKNOWLEDGMENT

I understand that receiving in-person healthcare services may increase exposure to communicable illnesses, including but not limited to COVID-19, influenza, RSV, or other infectious conditions.

I acknowledge that Houston Concierge Medicine cannot guarantee prevention of exposure.

I agree to notify the Practice if I develop symptoms of a contagious illness or have known exposure prior to appointments or house calls.

CONSENT TO TREATMENT IN HOME OR WORKPLACE SETTINGS

If I request house call or mobile healthcare services, I understand that services may be rendered in my home, workplace, or alternate location.

I accept responsibility for maintaining a reasonably safe environment for Practice personnel during such visits.

I acknowledge that receiving services in these environments may involve additional privacy, safety, or exposure risks beyond the Practice’s control.

FINANCIAL RESPONSIBILITY AGREEMENT

I accept full financial responsibility for all services rendered by Houston Concierge Medicine that are not otherwise prepaid, covered by insurance, or included within my membership agreement.

I agree to pay all balances, fees, deductibles, copayments, membership fees, cancellation fees, product fees, testing fees, and other applicable charges associated with services rendered.

I understand that:

  • Payment may be required prior to services being rendered

  • Declined payments may result in suspension of services

  • Outstanding balances may be subject to collections efforts where permitted by law

  • I may be responsible for reasonable collection costs, attorney fees, and recovery expenses associated with unpaid balances

I authorize Houston Concierge Medicine to charge approved balances and recurring membership fees to the payment method maintained on file.

NO GUARANTEE OF RESULTS

I understand that medicine and wellness treatments are not exact sciences.

No guarantees, warranties, or assurances have been made regarding:

  • Treatment outcomes

  • Symptom improvement

  • Cosmetic results

  • Weight loss results

  • Hormone optimization results

  • Wellness outcomes

  • Longevity outcomes

  • Laboratory improvements

  • Disease prevention

Individual responses to treatment vary significantly.

RELEASE OF LIABILITY

To the fullest extent permitted by law, I acknowledge and accept the inherent risks associated with medical evaluation, treatments, procedures, telehealth services, wellness therapies, and elective services provided by Houston Concierge Medicine.

Except where prohibited by law, I agree that the Practice shall not be liable for indirect, incidental, consequential, or special damages arising from services rendered.

Nothing in this agreement waives rights that cannot legally be waived under applicable law.

MEDIATION & BINDING ARBITRATION AGREEMENT

I understand and agree that any dispute, claim, or controversy arising out of or relating to services provided by Houston Concierge Medicine, including claims involving negligence, malpractice, emotional distress, wrongful death, or financial disputes, shall first be submitted to non-binding mediation.

If mediation is unsuccessful, such disputes shall be resolved through final and binding arbitration rather than through litigation in court, except where prohibited by applicable law.

Arbitration shall be conducted in Houston, Texas before a mutually agreed neutral arbitrator or arbitration service.

I understand and agree that by entering into this arbitration agreement:

  • I am waiving my right to a jury trial

  • I am waiving the right to litigate disputes in court

  • Arbitration decisions are generally final and binding

  • Rights to appeal arbitration decisions are limited

Nothing herein prevents Houston Concierge Medicine from pursuing collections actions for unpaid balances in a court of competent jurisdiction.

GOVERNING LAW

This Agreement shall be governed by and interpreted in accordance with the laws of the State of Texas.

Any legal proceedings permitted outside arbitration shall be subject to the jurisdiction of courts located in Houston, Texas.

SEVERABILITY

If any portion of this Agreement is determined to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Any unenforceable provision shall be modified only to the extent necessary to make it enforceable under applicable law.

ENTIRE AGREEMENT

This document constitutes the entire Consent to Treat, Telehealth Consent, Financial Responsibility, and Dispute Resolution Agreement between the patient and Houston Concierge Medicine unless otherwise modified in writing by the Practice.

ACKNOWLEDGMENT & VOLUNTARY CONSENT

By signing below, I acknowledge and agree that:

  • I have read and understand this Agreement

  • I have had the opportunity to ask questions

  • My questions have been answered to my satisfaction

  • I voluntarily consent to treatment and services

  • I understand the risks, benefits, and alternatives associated with treatment

  • I understand and voluntarily agree to the mediation and arbitration provisions contained herein

  • I understand this Agreement is legally binding

 

Our Contact:

Houston Concierge Medicine

9432 Katy Freeway, Suite 400
Houston, Texas 77055

Call or Text: 713-333-6464
Fax: 832-203-4068
Email: info@houstonconciergemd.com
Website: https://www.houstonconciergemedicine.com/

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