360 Health Integrated Medical Boutique, PLLC
Patient Terms and Agreement

This agreement outlines the policies, terms of care, and patient responsibilities when receiving services at 360 Health Integrated Medical Boutique (“360 Health IMB”, “we”, “our”, or “clinic”). By signing or consenting to services, you acknowledge and agree to the following:

1. Medical Services & Consent to Treat

I understand and agree that:

360 Health IMB provides medical, wellness, and weight management services, including but not limited to: primary care, obesity treatment, GLP-1 weight loss therapies, hormone therapy, IV hydration, and health coaching.
I voluntarily consent to be evaluated and treated by a licensed provider at this clinic.
I will be informed of the purpose, risks, benefits, and alternatives to recommended treatments, including the use of compounded or off-label medications.

2. Insurance & Self-Pay Policy

I understand that 360 Health IMB accepts insurance for primary care services only.
All non-primary care services (e.g., weight loss medications, compounded injections, hormone therapy, IV therapy, wellness coaching) are self-pay only and not billable to insurance.
I am responsible for knowing the details of my insurance coverage and will provide accurate and updated insurance information prior to my primary care visit.

3. Financial Agreement & Payments

Payment for self-pay services is due in full at the time of service.
Insurance co-pays, deductibles, and any uncovered charges for primary care visits must be paid according to the explanation of benefits provided by my insurer.
No refunds will be given for services already rendered or products purchased.
If enrolled in a membership, payment plan, or subscription, I authorize recurring charges and agree to the cancellation policy as outlined in my service agreement.

4. Cancellations & No-Shows

Appointments must be canceled or rescheduled with at least 24 hours’ notice.
A $50 fee applies for no-shows or late cancellations.
Excessive no-shows may result in a pause or termination of services.

5. Confidentiality & Communication

360 Health IMB complies with all HIPAA regulations to protect the confidentiality of my medical information.
I authorize the clinic to communicate with me via phone, email, and/or SMS about appointments, test results, health information, and promotions. I may opt out of marketing communications at any time.
I agree not to record visits without written permission from the provider.

6. Patient Responsibilities

I agree to provide accurate, complete health and medication information and to notify the clinic of any changes to my medical status.
I will follow the treatment plan, including lab work, follow-ups, or referrals as instructed.
I understand that noncompliance with my care plan may affect outcomes and result in discharge from the clinic.
I will maintain respectful conduct when communicating with staff and during visits.

7. Medical Disclaimer

I understand that results from treatments, including weight loss programs and hormone therapy, may vary based on individual factors.
Compounded medications may not be FDA-approved but are produced by FDA-regulated compounding pharmacies.

8. Dispute Resolution

I agree to attempt to resolve any disputes through informal discussion, then mediation or arbitration, before pursuing legal action.
This agreement is governed under the laws of the State of Texas.

9. Updates to Terms

360 Health IMB may revise these terms at any time. I will be notified of changes, and my continued use of services constitutes acceptance of the updated terms.

By signing below, I acknowledge that I have read, understood, and agreed to the above policies.

Patient Name: ___________________________
Signature: _______________________________
Date: _____________

Terms and Conditions