Telehealth and Medication Consent

This Telehealth and Medication Consent (this Consent) explains how care is delivered through Sipra LLC, a Wyoming limited liability company ("Sipra"), the medications, risks, and your rights. It applies to every visit, message, and prescription on the platform.

Clinical care is provided by MDI Medical Group PC and its affiliated state professional corporations ("MD Integrations"), your treating provider and the HIPAA Covered Entity ("CE"). Sipra is the technology platform and acts as a HIPAA Business Associate ("BA") to MD Integrations under a Business Associate Agreement. Sipra and MD Integrations are separate entities; this Consent does not establish a Joint Notice of Privacy Practices, Affiliated Covered Entity, or Organized Health Care Arrangement. This is a CE-BA relationship under 45 CFR 164.502(e) and 164.504(e).

Cross-references: Terms of Service · Privacy Policy · HIPAA Notice of Privacy Practices · Important Safety Information · Refund and Cancellation Policy.

You must be 18+ and physically in the United States.

"Telehealth" means health care delivered using technology when you and your provider are in different places, secure messaging, forms, photo/document upload, voice calls, and video visits.

A licensed physician can review your history, order tests, and prescribe treatment. Telehealth does not replace emergency care or in-person care your physician decides you need.

Asynchronous ("store-and-forward"): you submit information through forms, photos, and messages on your time; your physician reviews and replies later. Synchronous: you and a physician talk in real time by phone or video.

Your physician chooses the format that fits your care; you can request a synchronous visit at any time. We will not describe an async-only visit as "audio-video" care.

Sipra is not for medical emergencies. For life-threatening symptoms, call 911 or go to the nearest ER.

For mental health crisis or suicidal thoughts, call or text 988 (Suicide and Crisis Lifeline) any time.

For urgent non-emergency treatment questions, message us in the patient portal.

• Access to a licensed physician without travel.
• Faster scheduling than many in-person clinics.
• Continuity through messaging, follow-ups, and dose check-ins.
• Direct shipping to your home.
• 24/7 clinical support for urgent treatment questions.

By accepting, you acknowledge each:

• No in-person exam. Your physician relies on what you share; findings can be missed.
• Limits of remote review. Some conditions need in-person testing, imaging, or hands-on care.
• Technology failures. Outages, bugs, device issues, or call drops can delay care.
• Information gaps. Incomplete or inaccurate intake answers can lead to a wrong dose or plan.
• Security risk. No system is perfectly secure. We use encryption and HIPAA-grade safeguards, but breach risk is never zero.
• Delays. Async review takes time. Plan ahead for refills and dose changes.
• Wrong fit. Your physician may decide telehealth is not right for you and refer to in-person care.

Alternatives include:

• In-person visit with a primary care physician, endocrinologist, or weight-management specialist.
• Urgent care or retail clinic.
• Emergency room for acute, severe symptoms.
• FDA-approved brand-name medication via your own provider's prescription at a local pharmacy.
• Lifestyle approaches, nutrition, exercise, behavioral therapy.
• Surgical options, including bariatric surgery, evaluated by an in-person specialist.
• Not starting treatment now.

Your decision to use Sipra is voluntary; you can seek a second opinion at any time.

Some plans use compounded medications, made by a licensed 503A compounding pharmacy under a patient-specific prescription from your physician. Read each carefully:

• Not FDA-approved. Compounded medications are not FDA-approved for safety or effectiveness. They may be prescribed when commercially available FDA-approved drugs do not meet your specific needs.
• Patient-specific prescription with documented medical necessity. Each compounded medication is dispensed pursuant to a patient-specific prescription based on your individual clinical assessment. Under FDCA §503A, these are not stock products. The prescribing clinician documents the clinical rationale (e.g., excipient allergy, dose unavailability, or combination need) in your medical record, and the compound reflects that rationale.
• Not a generic; no representation of equivalence. Compounded semaglutide, tirzepatide, and other compounded molecules are not generic versions of any FDA-approved branded product. Sipra does not represent compounded medications as "generic Ozempic," "generic Wegovy," "generic Mounjaro," "generic Zepbound," or otherwise as equivalents to FDA-approved branded products. Compounded medications are independent formulations under FDCA §503A. Sipra has no affiliation with Eli Lilly and Company or Novo Nordisk A/S.
• Combination ingredients. Some compounded formulations include added ingredients chosen by the prescriber and pharmacist, e.g., B6, glycine, or niacinamide with semaglutide; B12 with tirzepatide. These combinations support tolerability or stability based on clinical judgment but have not been studied in large FDA trials.
• No affiliation with brand makers. Sipra is not affiliated with, sponsored by, or endorsed by Eli Lilly and Company, Novo Nordisk A/S, or any other branded manufacturer. Both have publicly disputed compounding of branded molecules; compounded products through Sipra are not made by those companies.
• Individual results vary. We do not promise specific weight loss or any clinical outcome. Studies of FDA-approved GLP-1 drugs report average body weight loss of ~15% over a year, but individual results vary widely.
• Important Safety Information. Read the Important Safety Information ("ISI") before you start. It lists boxed warnings, contraindications, side effects, and interactions, and is incorporated here by reference.
• Your physician may prescribe a pre-authorized titration schedule for up to six months, with the dose advancing per the schedule each refill cycle subject to your physician's review and confirmation of your tolerance, side effects, and ongoing eligibility. Each refill is approved individually by your physician; titration does not auto-advance without physician sign-off.

Sipra also offers compounded GLP-1 at microdoses (~25% of standard) for general wellness. Risk-benefit differs from standard dose. By consenting, you specifically acknowledge:

• (a) microdose is not FDA-approved for any indication;
• (b) the safety and efficacy of microdose has not been clinically validated to the same standard as full-dose GLP-1;
• (c) the prescribing clinician has reviewed your specific clinical context for microdose appropriateness;
• (d) you have read the Important Safety Information for microdose; and
• (e) you may discontinue microdose at any time.

The clinical rationale, indication, dosing strategy, individual factors, is documented in your medical record consistent with the Section 8 503A patient-specific medical-necessity recital. Discontinue any time through the patient portal or at [email protected].

Your clinical relationship is with the affiliated medical practice (the HIPAA Covered Entity identified in Section 1). Each treating physician holds an active, unrestricted license in your state. Sipra is the technology platform; it does not practice medicine, diagnose, or prescribe.

Your physician keeps full clinical judgment, they can decline to prescribe, change a dose, order labs, or refer you to in-person care at any time.

Prescriptions are filled by Healthcare Prosoft, LLC (operating the VSDH One Platform), Epiq Scripts LLC, Valiant Compounding Pharmacy, and Perfect RX or a licensed retail pharmacy for brand-name products. You may also use any other licensed pharmacy of your choice.

Before your first visit, we verify identity using a government-issued ID photo, real-time selfie, and date of birth, used only to confirm identity.

Photo retention. ID image and selfie are retained for 30 days after verification, then destroyed. Sipra and its identity verification vendor do not extract biometric templates or faceprints from your photos. We do not enroll you in a face-recognition database. (See the Privacy Policy for biometric handling and the Consumer Health Data Privacy Policy for state-law disclosures.)

You must be physically in a state where Sipra operates at each visit, and you agree to confirm your location each visit. Practicing across state lines without this check is illegal; a false location can void your care.

Your care uses HIPAA-compliant technology with encryption in transit (TLS) and at rest (AES-256). See Section 1 for the CE-BA structure.

Recording policy. Sipra does not record telehealth visits by default. Recording requires explicit consent from both you and your clinician at the start of the visit. If a synchronous visit is recorded, your physician will tell you and ask for consent on the record before recording starts. (In Sipra's two-party-consent jurisdictions, CA, FL, IL, MD, MA, MT, NV, NH, PA, WA, recording without consent is unlawful.) Async messages are not recorded as audio or video; text and uploaded files are retained in the medical record.

Information exchange. By accepting, you authorize Sipra (BA), MD Integrations (CE), and contracted pharmacy partners to share information for treatment, payment, and health care operations under HIPAA, lab orders, prescription transmission, refills, fulfillment, follow-up. Pharmacy partner sharing occurs under separate BAAs or permitted treatment disclosures.

You have direct electronic access to your records under the 21st Century Cures Act and ONC Information Blocking Rule. Download from the portal or request secure transmission.

See the HIPAA Notice of Privacy Practices and Privacy Policy for full detail.

Some intake screening, dose calculation, and fraud-detection use automated tools. These tools support clinical decisions but do not make medical decisions. A licensed clinician reviews and approves all prescriptions and care plans.

Automated tools are limited to:

• Pre-screening intake for contraindications, flagged for clinician review.
• Suggesting starting doses and titration per prescriber protocols (the prescriber confirms or overrides).
• Detecting payment fraud, account abuse, or duplicate accounts.
• Routing messages to the appropriate queue.

A clinician exercises independent clinical judgment for every prescription, dose change, and care plan adjustment. You may ask how an automated tool was used in your care.

Sipra's recurring-intake system surfaces patient status to physicians for review and approval. The system does not approve, decline, charge for, or ship refills without an active physician decision for that specific refill.

Every prescription carries risk. Read the ISI before your first dose, it is the controlling source for warnings and contraindications.

GLP-1 medications carry a boxed warning about thyroid C-cell tumors (rodent studies). Tell your physician if you or a close relative has medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), these are contraindications.

Disclose any history of pancreatitis, gallbladder, kidney, severe GI, diabetic eye disease, or eating disorder before starting.

Drug interactions. Give your physician a complete medication list, prescription, OTC, vitamins, supplements, recreational. GLP-1 medications slow gastric emptying and can affect oral drug absorption.

Adverse event reporting. Report serious side effects to your physician immediately. You can also report to FDA MedWatch at 1-800-FDA-1088 or fda.gov/medwatch.

Do not use a GLP-1 medication if pregnant, possibly pregnant, or breastfeeding. Tell your physician immediately if you become pregnant or plan to during treatment.

Tirzepatide can reduce oral hormonal contraceptive effectiveness. Your physician may ask you to use a backup (e.g., barrier) or switch to a non-oral method for at least 4 weeks after starting tirzepatide and after each dose increase.

Pregnancy registry candor. If you become pregnant during compounded GLP-1 treatment, contact your clinician immediately. Compounded GLP-1 pregnancy registries may not be accepting submissions; pregnant patients are referred to obstetric care for shared decision-making. For FDA-approved branded GLP-1 products, manufacturers historically maintained registries, Eli Lilly at 1-800-LillyRx and Novo Nordisk at 1-800-727-6500. Your physician will help you identify which registry pathway, if any, applies and refer you to obstetric care.

Your physician may require lab work to confirm eligibility, screen for safety, and guide dose decisions; they will tell you which tests and how.

Treatment usually starts low and increases over time, dose titration. Follow your physician's schedule; do not change your dose on your own.

Expect regular check-ins on tolerance and side effects. Respond promptly so your physician can keep your dose safe.

Your physician may pause, change, or stop treatment based on progress, side effects, or new health information. You can ask to switch medications at any time.

GLP-1 medications and many peptides require refrigeration. Pharmacy partners ship in temperature-controlled packaging with cold packs, but packages can still be delayed or heat-exposed.

Inspect on arrival. If the package is damaged, cold packs warm, seal broken, or the medication looks wrong (cloudy, discolored, particulate), do not use it, contact us for replacement.

Store as directed. Keep out of reach of children and pets. Never share your medication.

17A. REFILLS, RENEWALS, AND ONGOING CARE

Each refill is subject to physician review and approval. Approximately 21 days before the end of your current paid period, we open a brief recurring check-in in your portal asking about your weight, side effects, dose tolerance, any new medications or conditions, and any concerns. Your physician reviews your check-in, your medical record, and your current dose, and decides whether to continue treatment, adjust your dose, or discontinue.

Charges. Your card is charged only when your physician approves your next refill. If your physician declines, you owe nothing.

Shipping cadence. Medication ships in plan-sized tranches: 1-Month plans ship monthly; 3-Month plans ship the full quarter in one shipment after physician approval.

If you don't complete your check-in. Your physician will review your existing record and may continue treatment at your prior dose for one more cycle, pause your subscription, or discontinue treatment. The decision is your physician's.

Mid-cycle dose changes. Send a portal message; your physician reviews and responds. Approved adjustments take effect at the next refill, not immediately.

Synchronous re-evaluation. Your physician may require an audio or video re-evaluation visit periodically or whenever clinically indicated. Refills cannot be approved without the required visit.

We do not charge you until your physician approves your treatment plan. If your physician declines treatment, you owe nothing. Charges in error are refunded.

Cancellation, pause, refund timing, and renewal price are governed by the Refund and Cancellation Policy.

You can withdraw this Consent at any time; we stop providing telehealth services. A final visit may be needed for safe wind-down (e.g., taper or transfer records).

Message us in the portal or email [email protected]. Withdrawal does not erase past records. We keep clinical records for 7 years after your last visit or longer if your state requires.

Sipra is available only in states where the affiliated medical practice's physicians are licensed and the law allows our model, see https://sipra.com/states.

Some states require extra disclosures or written consent. State-specific addenda apply for these 11 states: CT, NJ, VA, KY, GA, NY, CA, TX, FL, MS, LA. These addenda live at the URL above and are incorporated by reference. Final addenda content awaits outside counsel review. Where a state-specific addendum conflicts with this Consent, the addendum controls for that state.

Placeholders below confirm all 11 states will be addressed:

• NEEDS ATTORNEY REVIEW: Connecticut addendum (drafting in progress with outside counsel; will be added prior to or shortly after launch)
• NEEDS ATTORNEY REVIEW: New Jersey addendum (drafting in progress with outside counsel; will be added prior to or shortly after launch)
• NEEDS ATTORNEY REVIEW: Virginia addendum (drafting in progress with outside counsel; will be added prior to or shortly after launch)
• NEEDS ATTORNEY REVIEW: Kentucky addendum (drafting in progress with outside counsel; will be added prior to or shortly after launch)
• NEEDS ATTORNEY REVIEW: Georgia addendum (drafting in progress with outside counsel; will be added prior to or shortly after launch)
• NEEDS ATTORNEY REVIEW: New York addendum (drafting in progress with outside counsel; will be added prior to or shortly after launch)
• NEEDS ATTORNEY REVIEW: California addendum (drafting in progress with outside counsel; will be added prior to or shortly after launch)
• NEEDS ATTORNEY REVIEW: Texas addendum (drafting in progress with outside counsel; will be added prior to or shortly after launch)
• NEEDS ATTORNEY REVIEW: Florida addendum (drafting in progress with outside counsel; will be added prior to or shortly after launch)
• NEEDS ATTORNEY REVIEW: Mississippi addendum (drafting in progress with outside counsel; will be added prior to or shortly after launch)
• NEEDS ATTORNEY REVIEW: Louisiana addendum (drafting in progress with outside counsel; will be added prior to or shortly after launch)

An electronic signature, click-through, or checkbox acceptance is a valid signature under the federal E-Sign Act (15 USC §7001 et seq.) and the Uniform Electronic Transactions Act ("UETA") as adopted in your state, equivalent to a handwritten signature.

E-Sign Act §101(c) recital. By providing your electronic signature, you acknowledge: (a) you have received and reviewed this Consent in a form you can retain; (b) electronic signatures are legally equivalent to handwritten signatures under the federal E-Sign Act (15 USC §7001) and applicable state UETAs; (c) you may withdraw consent to electronic communications at any time by contacting [email protected] (in which case Sipra will provide paper copies for the cost of printing and mailing).

Hardware and software. You need a device with internet access, a current browser, an email account, and the ability to view, save, and print PDF and HTML files. If these requirements change so you may not be able to access or retain records, we will notify you and let you withdraw consent without fee.

Recordkeeping. We keep an electronic record of your acceptance (timestamp + Consent version). Request a copy at [email protected].

By checking the consent box and submitting, you confirm each statement below:

• I am 18+ and physically located in a Sipra-served U.S. state.
• I have read this Consent in full and had the chance to ask questions.
• I understand telehealth, its async and synchronous formats, and its risks and limits.
• I understand that compounded medications are independent formulations under FDCA §503A and are not FDA-approved, are not generic versions of Ozempic, Wegovy, Mounjaro, or Zepbound, and that Sipra is not affiliated with Eli Lilly and Company or Novo Nordisk A/S.
• I understand the additional risk and benefit profile of microdose GLP-1, that microdose is not FDA-approved for any indication, that microdose has not been clinically validated to the same standard as full-dose GLP-1, that the prescribing clinician has reviewed my specific clinical context, that I have read the Important Safety Information for microdose, and that I may discontinue microdose at any time.
• Individual results vary; no specific weight loss is guaranteed.
• I understand that Sipra will not charge me until my physician approves my treatment plan, and that if treatment is declined I owe nothing.
• I understand my card is charged at clinician approval and the prescription is sent to the pharmacy automatically; I cannot cancel after that point.
• I have read or have access to the Important Safety Information ("ISI") for my treatment, including for microdose if prescribed, and I understand the ISI is incorporated into this Consent by reference.
• I authorize information exchange among Sipra (BA), MD Integrations (CE), and contracted pharmacy partners for my care under applicable BAA(s) and HIPAA.
• I will give complete and accurate information, including a full medication list.
• I understand the recording policy: Sipra does not record telehealth visits by default; recording requires explicit consent from both me and my clinician at the start of the visit; and in two-party-consent jurisdictions (CA, FL, IL, MD, MA, MT, NV, NH, PA, WA) recording without consent is unlawful.
• I can withdraw this Consent at any time.
• I am providing my electronic signature to this Consent. I have received and can retain this Consent. I understand my electronic signature is legally equivalent to a handwritten signature under the federal E-Sign Act and applicable state UETA, and that I may withdraw consent to electronic communications at any time by contacting [email protected].
• I understand my treatment may include a physician-pre-authorized titration schedule for up to six months, that each refill remains subject to physician review and approval, and that I will not be charged for any cycle my physician declines.

• Patient support: [email protected]
• 24/7 support: via the patient portal
• Privacy and HIPAA complaints: [email protected]
• Legal notices: [email protected]
• Mailing address: 30 N Gould St, Ste R, Sheridan, WY 82801

You may also file a HIPAA complaint with HHS Office for Civil Rights, 200 Independence Ave SW, Washington DC 20201; 1-877-696-6775; ocrportal.hhs.gov.

We will not retaliate for questions, concerns, or complaints.