.svg){kind=logo}
Onsera Patient Consent to Care
Last updated: February 19, 2026
This is a consent form for services such as virtual care, obesity management, and medication therapy. It is also an authorization for usage of Health Information Exchanges (HIEs).
Patient Name: ___________________________________
Date: ____________________
1. Purpose of this consent
This consent form authorizes Onsera Health (“Onsera”) and its affiliated clinicians (the “Care Team”) to:
- Provide virtual, telehealth, and in-person care for obesity management.
- Evaluate and treat me using anti-obesity medications (AOMs), including compounded semaglutide, tirzepatide, or other GLP-1/GIP agents when clinically indicated.
- Obtain, use, and share my health information internally and through authorized Health Information Exchanges (HIEs), including Carequality, CommonWell, and other federated networks, to coordinate my care safely and efficiently.
2. Consent for virtual care & telehealth
I understand that:
- My care may be delivered through telehealth technologies, including video visits, phone calls, asynchronous messaging, and remote monitoring.
- Telehealth involves potential technological risks (e.g., interruptions, data issues), but Onsera uses HIPAA-compliant platforms.
- I will inform my provider if I experience any adverse symptoms or changes in my health.
- I must participate from a private, safe location and provide accurate information about my health, medications, and symptoms.
- If I am experiencing a medical emergency, I will call 911 or seek immediate in-person care and will not rely solely on telehealth.
3. Consent for obesity management treatment
I authorize Onsera to assist in my weight-management treatment, which may include:
- Medical evaluation
- Nutritional counseling
- Behavioral and lifestyle guidance
- Medication therapy, including FDA-approved medications or compounded medications from reputable pharmacies meeting national quality and safety standards
I understand that anti-obesity medications may be prescribed off-label, at doses higher or lower than listed in FDA labeling, at my clinician’s discretion based on medical judgment, clinical guidelines, and recent evidence.
4. Patient responsibilties
I agree to:
- Follow the treatment plan provided by my Care Team.
- Disclose all medications, supplements, and herbal products I take.
- Report significant symptoms or side effects promptly.
- Attend scheduled appointments and follow Onsera’s cancellation and “no-show” policies.
- Understand that missing more than two consecutive treatment weeks may require re-evaluation, re-dosing, and additional fees.
- Complete requested baseline and periodic lab work which is required for treatment with anti-obesity medications, such as GLP-1s, Contrave, and metformin.
- Confirm I am physically located in a state where my Onsera (or Hello Alpha) provider is licensed to practice medicine at the time of each visit.
I understand that success depends greatly on my participation and lifestyle changes, and that no outcome is guaranteed.
5. Risks of proposed treatment
I understand that:
Common Side Effects:
Nausea, vomiting, constipation, diarrhea, abdominal discomfort, fatigue, headache, injection-site irritation.
Less Common but Serious Side Effects:
Common Side Effects:
Nausea, vomiting, constipation, diarrhea, abdominal discomfort, fatigue, headache, injection-site irritation.
Less Common but Serious Side Effects:
Alcohol Considerations
I understand there are reports of drastically reduced alcohol tolerance while on semaglutide/tirzepatide, and alcohol may also increase nausea or vomiting.
I agree to use caution driving or operating machinery after consuming alcohol.Nausea, vomiting, constipation, diarrhea, abdominal discomfort, fatigue, headache, injection-site irritation.
Obesity-Related Health Risks
Remaining overweight or obese carries significant risks including hypertension, diabetes, heart disease, joint disease, sleep apnea, and increased mortality.
Regaining Weight
Weight regain is possible even after successful treatment. Long-term lifestyle changes are essential.
6. Contraindications
I affirm that I do not have any of the following conditions unless disclosed and reviewed:
- Age under 18
- Pregnancy / Breastfeeding / Trying To Conceive: I confirm I am not pregnant or planning to become pregnant in the next two years. I will immediately notify Onsera if my status changes. I am aware that the medications prescribed through Onsera can cause birth defects or fetal harm
- Type 1 Diabetes or diabetic ketoacidosis
- Prior allergic reaction to semaglutide, tirzepatide, or GLP-1 medications
- Personal or family history of medullary thyroid carcinoma (MTC)
- History of Multiple Endocrine Neoplasia Type 2 (MEN2)
- History of pancreatitis
I understand that final eligibility is determined by the clinical judgment of my Onsera provider.
7. Alternatives to treatment
I understand alternatives include:
- Diet and exercise alone
- Other pharmaceutical medications
- Non-medical weight-loss programs
- Bariatric surgery (when clinically appropriate)
8. Consent for health information exchange (HIE) & carequality
I understand and authorize Onsera to:
- Exchange, obtain, and share my health information electronically through Carequality, CommonWell, and other connected Health Information Exchanges (HIEs) for purposes of treatment, care coordination, medication safety, and continuity of care.
- Retrieve medical records, labs, imaging, medication histories, and care summaries from participating providers, health systems, pharmacies, and insurers.
- Share relevant information with those organizations when they are involved in my care.
I understand:
- Only information necessary for treatment and care coordination will be shared.
- This exchange is HIPAA-compliant and uses secure, encrypted networks.
- I may opt out of HIE sharing by submitting a written request, understanding that opting out may limit safe and complete care.
I authorize this exchange of information until revoked by me in writing
9. Photography & medical record documentation
I consent to clinical photographs or videos for documentation, diagnostic review, and treatment planning.
I also consent to de-identified use for education or training.
My name will not be used in any publication.
I also consent to de-identified use for education or training.
My name will not be used in any publication.
10. Limitations on Liability
I authorize Onsera to contact me via:
for scheduling, follow-ups, clinical communication, and care coordination.
I understand that electronic communication carries some privacy risks.
11. Financial responsibility
I understand that:
- Treatment through Onsera is elective and typically not covered by insurance.
- Payment is due at the time of service and non-refundable.
- Any outside medical care, emergency services, labs, or imaging are my financial responsibility.
12. No guarantee of results
I acknowledge that:
- Weight loss and health improvement vary by individual.
- No guarantees or promises about specific results have been made.
13. Patient acknowledgement & signature
I certify that:
- I have read this entire document or had it read to me.
- I understand the risks, benefits, and alternatives of treatment.
- All my questions have been answered to my satisfaction.
- I voluntarily agree to treatment with Onsera, including telehealth, obesity-management care, medication therapy, data sharing through HIE networks, and all elements outlined above.
Patient Signature: ___________________________________
Date: ____________________
Provider Signature: __________________________________
Date: ____________________
Date: ____________________
Provider Signature: __________________________________
Date: ____________________