Telemedicine Informed Consent

This informed consent applies to patients of:

• Telegenix Provider Group, P.A., a Florida professional services association
• Telegenix Provider Group CA, P.C., a California professional services corporation
• Telegenix Provider Group KS, P.A., a Kansas professional services association
• Telegenix Provider Group NJ, P.C., New Jersey professional services corporation
• Telegenix Provider Group, LLC, an Oregon professional services corporation

Each Provider Group listed above is individually a “Practice”.

The purpose of this Telemedicine Informed Consent (“Consent”) is to ensure that you are fully informed about the procedures, benefits, risks, and alternatives associated with the evaluation and treatment provided by the Practice, and to obtain your voluntary agreement to proceed with such evaluation and treatment.

What is Telemedicine?

Telemedicine is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare practitioner.

Benefits of Using Telemedicine

The benefits of telemedicine include having access to medical care anywhere you have access to the internet—including from the comfort of your home. Telemedicine means you don’t risk exposure to illness in busy waiting rooms, and you do not have to wait several days for an in-person appointment. Telemedicine also means you do not have to travel great distances to gain access to specialty care that may not be available in your community.

Possible Risks of Using Telemedicine

As with any medical treatment, there are potential risks associated with the use of telemedicine. These risks may include, without limitation, the following:

• Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor video and data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your healthcare practitioner should these interruptions occur. If you need assistance in the event of a telemedicine equipment failure, please contact us at: telegenix@singlethreadhealth.com.
• Security protocols could fail, causing a breach of privacy of personal medical information.
• Because Practice does not have access to your complete medical records, if you do not disclose to your Provider a full list of your medical history, including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions, or allergic reactions, or other negative outcomes may occur.
• Telemedicine services are NOT emergency services, and your personal data WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.

THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE PROVIDER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTHCARE PRACTITIONER WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR A TELEMEDICINE ENCOUNTER VIA THE SERVICE.

Your Rights and Acknowledgements

• You acknowledge you have been informed of the potential risks and benefits associated with the proposed evaluation and treatment. This includes, but is not limited to, the expected benefits of improved health and well-being, as well as the potential risks of side effects, allergic reactions, or other adverse outcomes that may arise from the treatment.
• You understand that while the goal of treatment is to improve health, no guarantees can be made regarding the outcome of any evaluation or treatment.
• You acknowledge you have had the opportunity to ask questions and seek clarification regarding the proposed evaluation and treatment, including inquiries about alternative treatments and their associated risks and benefits.
• You understand that you have the option to refuse a telehealth visit at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any benefits to which you would otherwise be entitled.
• You understand that there are no additional or hidden fees associated with the use of telemedicine.
• You understand that your healthcare information may be shared with other individuals in accordance with the Telegenix, LLC, Privacy Policy and regulations or laws in the state or territory in which you are located. You further understand that you have the right to request disclosure of your Healthcare Information to any third party, and that such disclosure will be made upon Practice’s receipt of your signed written authorization.
• You understand that dissemination of any identifiable images or information from the telemedicine visit to researchers or other entities will not occur without your express written consent.
• Telemedicine may involve electronic communication of your personal medical information to remote healthcare practitioners who may be located outside of your state.
• You have the same privacy rights via telemedicine that you would have during an in-person visit.
• You understand that no results can be guaranteed or assured—you may not achieve the anticipated benefits of the telemedicine services.
• You understand that a variety of alternative methods of medical care may be available to you, and that you may choose one or more of these at any time.
• You understand that all information submitted to Practice will be part of your medical record, and you have the right to review and receive copies of your medical records in accordance with applicable law. For more information on how to access your medical records, please contact telegenix@singlethreadhealth.com.
• You understand that your telemedicine visit may be with a non-physician provider. You may request that your telemedicine visit be scheduled with a physician.
• You will provide your accurate physical location when asked by a Provider (and/or this information could be collected as a part of the intake process by the technology platform(s) used to facilitate your telemedicine visit), to ensure that Provider is licensed to provide telemedicine services to you. Your Provider will validate this prior to commencing your visit.
• You consent to the disclosure of any medical records prepared by Practice to your primary care provider.
• Depending on your medical history, symptoms, laboratory results, goals, contraindications, and response to prior treatment, Provider may recommend one or more prescription medications, compounded preparations, or adjunctive therapies delivered by oral, topical, sublingual/troche, or injectable route. These may include treatments for metabolic health and weight management, hair or skin conditions, hormone/endocrine or fertility support, nausea or symptom relief, and certain peptide-, vitamin-, or nutrient-based therapies. You understand that not every treatment category applies to every patient and that only the medication(s) actually recommended for you will be discussed and offered.
• Some medications recommended through this program may be compounded or customized. You understand that compounded drugs are not FDA-approved, may differ from commercially available products, and may be used when Provider determines that a customized formulation, strength, combination, dosage form, or route of administration is medically appropriate for you.
• Some medications may be prescribed in a manner not specifically described in FDA-approved labeling, including for a different indication, dose, combination, dosage form, or route of administration. If this is recommended for you, Provider will explain why it is being recommended, the expected benefits, the material risks, available alternatives, and the option of no treatment.
• Medication risks vary depending on the treatment actually prescribed. Depending on the medication, potential risks may include gastrointestinal upset; appetite or weight changes; headache, dizziness, fatigue, sleep changes, palpitations, or blood-pressure changes; mood, libido, sexual-function, menstrual, or fertility changes; hair or skin changes; allergic reactions; injection-site reactions; dosing or administration errors with self-administered medications; and abnormal laboratory values affecting liver, kidney, thyroid, glucose, lipids, or hormone levels. You understand and acknowledge that not every risk listed applies to every medication, and that the medication-specific risks relevant to your treatment have been reviewed with you.
• You understand that laboratory monitoring may be required before and during treatment and failure to complete required monitoring may result in suspension or discontinuation of therapy.
• If, after evaluation, Provider recommends a controlled substance, you understand that its prescription by telemedicine is subject to additional federal and state requirements and may require enhanced identity verification, follow-up, monitoring, or an in-person evaluation before or during treatment. You understand that controlled substances may carry risks of misuse, dependence, and diversion, and you agree to use the medication only as prescribed, not share or transfer it, store it securely, and comply with all recommended follow-up and monitoring requirements.
• You understand that if a medication is actually recommended, you will be offered medication-specific information regarding its name, purpose, expected benefits, common and serious side effects, contraindications, monitoring, alternatives, and when to seek urgent or emergency care. If a medication is self-administered by injection, you will receive instructions on storage, dose measurement, administration, and disposal.
• You confirm that you have disclosed all current medications, supplements, and recreational substances you may be using. Failure to disclose medications may increase risk of serious complications.

If you would like to withdraw consent, you may do so at any time by emailing us at telegenix@singlethreadhealth.com. Your withdrawal of consent will not affect your right to future care or treatment.