Client Informed Consent to Treatment

By clicking “I Agree,” checking a box to indicate your acceptance, using any other method of acknowledgment provided through the Fountain platform, or otherwise affirmatively accepting this consent, you confirm that you have read, understood, and agree to the terms outlined in this consent. If you do not agree to these terms, please do not use the service. If someone is accepting these terms on your behalf, you confirm that they are authorized to do so.

If you are experiencing a life-threatening emergency or are in crisis, please call 911 or contact the Suicide & Crisis Lifeline by dialing 988. Immediate help is available.

Background

Fountain NYC Medical PLLC (“Fountain” or the “Practice”) is a psychiatric medical practice that provides treatment services through a technology-enabled platform. This platform facilitates access to psychiatric care delivered via telehealth and, when appropriate, in-person services. Fountain is an independently owned and operated medical practice and is not affiliated with any third-party corporate ownership.

As part of the services provided, your clinician may prescribe medications to support treatment in the areas of mental health, weight management, sexual health, hormonal health, anti-aging, and mental clarity. Some of these medications may be compounded by licensed pharmacies under Section 503A of the federal Food, Drug, and Cosmetic Act (FDCA). Compounded medications do not require FDA approval, and while they may contain active ingredients that are FDA-approved for other uses, the compounded formulations themselves have not been evaluated by the FDA for safety or efficacy for the specific uses prescribed.

Medications may be prescribed as part of your treatment plan when deemed clinically appropriate by your provider. These include prescription medications designed to support mental health, weight management, hormonal optimization, sexual health, anti-aging, and cognitive performance. Some of these medications may be compounded in custom formulations (such as tablets, troches, injectables or liquids) by licensed pharmacies operating under Section 503A of the federal Food, Drug, and Cosmetic Act (FDCA). These compounded medications are not required to undergo FDA approval, and while they may contain active pharmaceutical ingredients that are FDA-approved for other uses, the compounded formulations themselves have not been evaluated by the FDA for safety or efficacy for the specific uses prescribed.

As with all prescription medications, compounded therapies and other treatments carry risks and may not be appropriate for everyone. Your provider will thoroughly review your medical history, goals, and symptoms to determine whether these therapies are safe and appropriate for your individual treatment plan.

Use of Telehealth

Fountain provides treatment services through a secure, technology-enabled platform that facilitates care between patients and licensed healthcare providers who may not be in the same physical location. Telehealth may be used for evaluation, diagnosis, treatment, follow-up, and patient education. This may include—but is not limited to—the electronic transmission of personal health information, medical records, photo images, lab results, and data from medical devices, as well as real-time interactions through audio, video, secure messaging, or other digital communication tools.

Telehealth allows Fountain providers to deliver high-quality psychiatric and wellness care in a convenient and accessible format, while also maintaining standards consistent with in-person medical practice. While telehealth may not be appropriate for all conditions, it is a core component of Fountain’s care model. In-person services may also be available, and you may request or be referred for in-person care at any time, depending on your clinical needs and provider recommendation. You are encouraged to discuss all care delivery options with your provider to determine what is best for your treatment plan.

Anticipated Benefits

The use of telehealth through Fountain may offer a number of potential benefits. These include more convenient and efficient access to medical and psychiatric care, flexible scheduling that allows you to engage with your provider at times that fit your lifestyle, and the ability to receive treatment from your home or other private settings without requiring an in-person visit.

Telehealth may also make it easier to begin or maintain treatment for a range of conditions treated by Fountain providers, including those related to mental health, weight management, hormonal health, sexual health, cognitive function, and aging. Participation in mental health or wellness services—whether through telehealth or in-person care—may reduce stress, improve mood, enhance relationships, and help increase overall confidence and comfort in a variety of settings.

Potential Risks and Limitations of Telehealth

While telehealth offers convenient, flexible, and effective access to care, there are certain limitations and risks associated with its use. In some cases, your provider may be limited in their ability to conduct a full physical exam or observe certain clinical signs through a virtual setting, which could affect the accuracy of diagnosis or treatment. If needed, your provider may recommend an in-person evaluation or additional testing. As with any technology, occasional disruptions—such as internet connectivity issues, software errors, or device malfunctions—may temporarily impact communication, documentation, or the delivery of care. Although Fountain uses HIPAA-compliant platforms and industry-standard security protocols, there is always a minimal risk that electronic communication could be improperly accessed or disclosed. Additionally, depending on your physical location and local regulations, certain treatment options or prescription medications may be limited or unavailable via telehealth. Your provider may also not have access to your complete medical history at the time of your visit, which could potentially affect clinical decision-making, including the identification of adverse drug interactions or allergies. Finally, participation in mental health treatment may sometimes bring up difficult emotions as part of the therapeutic process. Fountain providers will work closely with you to address any concerns, determine whether telehealth is appropriate for your needs, and recommend alternative care when necessary.

Life Threatening and Other Emergency Situations

If you are experiencing a life-threatening situation such as contemplating suicide, call 911 or the 988 Suicide & Crisis Lifeline at 988.

If the situation is an emergency, call 911. In some situations, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. Providers may not respond promptly to communications you submit through the Service. If you are not experiencing an emergency or do not require immediate or urgent care, you can communicate with Providers through the secure message service in the Service. If a technical failure prevents you from communicating with your Providers through the Service, you should call the following number: Phone: 1-818-421-0242 (M-F 9AM – 5PM EST).

Data Privacy and Protection

The electronic systems used by Fountain incorporate industry-standard network and software security protocols to protect the privacy and security of your information. These systems include measures designed to safeguard data against both intentional and unintentional access, loss, or corruption. Personal information that identifies you, including your protected health information (PHI), will not be disclosed to any third party without your consent, except as permitted or required by law. This may include disclosures for treatment, payment, administrative functions, or when legally obligated—such as in cases involving a risk of harm to yourself or others, or mandatory reporting of child, elder, or vulnerable adult abuse. Communications between you and your provider may include electronic messages, including email, which could contain protected health information. While Fountain takes steps to protect your privacy, you acknowledge that third-party services used to receive communications (such as your personal email provider) are not under Fountain’s control, and we cannot guarantee the security of those external services.

Your Acknowledgements

By clicking “I Agree,” checking a related box to indicate your acceptance, using any other acceptance mechanism presented through the Fountain platform, or otherwise affirmatively acknowledging this consent, you are confirming that you have read, understood, and agree to the terms outlined in this informed consent. You are providing your voluntary consent to receive treatment through Fountain, including telehealth-based services and, when applicable, in-person care. You acknowledge that you have had the opportunity to ask questions, that you understand the risks and benefits of the proposed treatments, including the use of compounded medications, and that you consent to the use of electronic systems to communicate, deliver care, and store your information as described in this document.

Healthcare and mental health services provided through Fountain are delivered via a secure, technology-enabled telehealth platform. All clinical care, including evaluation, diagnosis, and treatment, is provided exclusively by licensed and credentialed healthcare professionals, which may include physicians, nurse practitioners, physician assistants, and licensed mental health clinicians. Your therapy services, if applicable, will be provided by licensed mental health professionals such as licensed professional counselors or equivalent.

As with any evolving healthcare technology, certain systems used to deliver care—including the telehealth platform itself—may still be undergoing ongoing improvements or may experience intermittent limitations. Although Fountain utilizes secure, HIPAA-compliant systems, technology may occasionally experience disruptions, software bugs, or temporary outages that could impact functionality, data transmission, or record-keeping. In rare cases, these issues could affect communication with your provider or the documentation of your care.

Diagnostic testing services, including laboratory testing that may be recommended by your provider, are performed by third-party laboratory partners. These labs are not owned or operated by Fountain. As with any lab-based service, there is a potential for delays, errors in results, or limitations in testing capabilities that could influence clinical decisions.

The delivery of care via telehealth also has inherent limitations, such as the provider’s inability to perform certain physical assessments or observe specific visual cues that might be more evident in an in-person setting. As a result, not all conditions can be evaluated or treated effectively via telehealth. If your provider determines that your condition requires in-person evaluation, additional diagnostics, or referral to a specialist, you will be advised accordingly.

No specific results or clinical outcomes from the use of telehealth or associated technology can be guaranteed. You understand that telehealth services may not lead to improvement in your condition, and in some cases, your condition may remain unchanged or worsen.

You also understand that the use of this platform involves the electronic transmission of your personal and medical information, which may include email communications or other forms of digital messaging. Fountain maintains strong security protocols to protect this data, but cannot guarantee the privacy of communication services outside its control (e.g., your email provider).

You are expected to provide complete, truthful, and accurate information about your health, medical history, and any current or past treatments received from other healthcare or mental health providers, including local emergency contact information. Your provider will assess your condition and determine whether diagnosis and/or treatment through telehealth is clinically appropriate. By continuing to use the Fountain platform, you agree with your provider’s assessment and consent to receive care through telehealth.

You may withdraw your consent to the use of telehealth at any time by providing written notice to your provider. Withdrawal of consent will not affect any care already provided or documented prior to receipt of such notice and does not affect your eligibility for future care from other providers. You acknowledge that Fountain’s providers deliver care via telehealth and, when clinically appropriate or preferred, may also offer in-person services as part of your treatment plan.