Follow-Up and Records Consent Form

Welcome to Glowform.

Before proceeding with your follow-up process, please read and acknowledge this Follow-Up and Records Consent Form. This form supplements the Telehealth Consent Form you may have previously accepted and explains how Glowform may collect, process, share, store, and maintain your personal and health information for follow-up coordination, patient records, progress monitoring, lab-related coordination where applicable, and continuity of care.

1. Nature and Purpose of Follow-Ups

Glowform’s follow-up process is intended to support patient safety, treatment monitoring, continuity of care, and proper coordination with the licensed physician during your Glowform journey.

As part of this process, you may be asked to provide or confirm your personal details, share health updates, submit progress information, complete recommended laboratory tests where applicable, provide lab results if available, and participate in follow-up consultations or medical reviews with a licensed physician.

Glowform helps facilitate follow-up coordination, communication with the licensed physician, delivery of physician-issued lab requests where applicable, scheduling of follow-up consultations, customer support, reminders, and maintenance of follow-up records.

Glowform does not independently diagnose medical conditions, interpret lab results, prescribe medication, or determine whether any treatment should be continued, adjusted, paused, or discontinued. Any medical assessment, lab result interpretation, treatment guidance, prescription, or recommendation will be made by the licensed physician.

2. Role of the Licensed Physician

The licensed physician is responsible for reviewing your submitted information, issuing lab requests where appropriate, reviewing lab results if available, conducting follow-up consultations or medical reviews, and providing medical guidance based on your condition, progress, and available information.

You understand that the final decision to continue, adjust, pause, or discontinue any treatment rests with the licensed physician.

Glowform’s role is limited to coordination, communication, administrative support, records management, reminders, and related platform services.

3. Laboratory Tests and Lab Results, Where Applicable

As part of your follow-up process, laboratory tests may be recommended so the physician can better assess relevant health markers and your overall response during your program.

If you agree to proceed with recommended labs, Glowform may collect your personal details and share them with the licensed physician for the purpose of preparing your patient records and issuing the lab request.

You may complete the laboratory tests at any diagnostic center convenient for you. Lab test fees are paid directly to the diagnostic center, unless otherwise stated. You may also check with your chosen diagnostic center if the tests may be covered by your HMO or insurance, subject to their own approval and requirements.

Once your lab results are available, you may submit them to Glowform so these can be shared with the licensed physician for review and follow-up consultation.

If you choose to defer or not proceed with labs, Glowform may still help coordinate your follow-up consultation or medical review. You understand that without lab results, the physician’s guidance may be based on your symptoms, progress, health updates, and feedback alone, which may be less complete than a review that includes laboratory results.

4. Consent for Collection, Processing, Sharing, and Storage of Information

To facilitate your follow-up process, Glowform may collect, process, store, and maintain your personal and health information, including but not limited to your name, age, sex, birthday, address, contact number, email address, health assessment information, consultation details, lab requests, lab results where available, physician notes or instructions, treatment-related updates, follow-up status, and related records.

This information may be used for the following purposes:

Preparing and maintaining your patient records;

Coordinating with the licensed physician;

Facilitating lab request issuance where applicable;

Receiving and organizing lab results where available;

Arranging follow-up consultations or medical reviews;

Supporting treatment monitoring and continuity of care;

Documenting follow-up status and next steps;

Providing customer support, reminders, and operational coordination;

Complying with legal, regulatory, and record-keeping requirements; and

Improving Glowform’s services and internal processes.

Your information may be shared with licensed physicians, relevant healthcare or service providers, customer support providers, and other trusted service providers only as necessary to facilitate the follow-up process and related services.

Glowform handles personal information in accordance with applicable data privacy laws, including the Philippine Data Privacy Act of 2012, and subject to Glowform’s Privacy Policy.

5. Records Keeping and Follow-Up Monitoring

You authorize Glowform to maintain records related to your follow-up process, including your follow-up status, lab request status where applicable, lab result submission where available, consultation schedule, physician review status, reminders, and related operational notes.

These records may be used to help ensure that follow-ups are properly coordinated, reminders are sent when appropriate, and continuity of care is supported.

You understand that clinical notes, medical advice, lab result interpretations, prescriptions, and treatment decisions remain under the responsibility of the licensed physician.

6. Patient Responsibilities

By proceeding with the follow-up process, you agree to:

Provide accurate, complete, and updated personal and health information;

Ensure that any information provided for your records or lab request is correct;

Submit clear and complete lab results if you complete recommended labs;

Inform Glowform or the licensed physician of any new symptoms, side effects, medications, allergies, diagnoses, or changes in your health condition;

Attend or respond to follow-up consultation schedules where applicable;

Follow the physician’s medical guidance and safety instructions; and

Seek urgent medical care if you experience severe symptoms or any emergency medical concern.

Glowform’s follow-up process is not intended for medical emergencies. If you experience severe allergic reactions, chest pain, difficulty breathing, fainting, severe abdominal pain, or any urgent medical concern, you should seek immediate medical attention or go to the nearest emergency facility.

7. Acknowledgment and Consent

By checking the box and submitting your information, you confirm that:

You have read and understood this Glowform Follow-Up and Records Consent Form;

You consent to participate in Glowform’s follow-up process;

You authorize Glowform to collect, process, store, maintain, and share your personal and health information as needed for follow-up coordination, patient records, progress monitoring, lab-related coordination where applicable, and records keeping;

You understand that Glowform facilitates coordination but does not independently diagnose, prescribe, interpret lab results, or make treatment decisions;

You understand that medical assessments, lab result interpretations, prescriptions, and treatment guidance are provided by the licensed physician;

You understand that labs may be recommended for a more complete follow-up review, but follow-up may still proceed without labs where appropriate;

You understand that if you defer or proceed without labs, the physician’s guidance may be based on your symptoms, progress, and feedback alone;

You agree to provide accurate and complete information; and

You understand that Glowform’s follow-up process is not for medical emergencies.