TELEHEALTH CONSENT FORM
Last Updated: August 5, 2026
CONSENT TO TELEHEALTH; TREATMENT-SPECIFIC CONSENT; CONSENT TO TELEPHONE, TEXT, AND EMAIL COMMUNICATIONS; AUTHORIZATION TO USE AND DISCLOSE MEDICAL INFORMATION; AND ASSIGNMENT OF BENEFITS
This Telehealth Consent Form applies to healthcare services furnished by licensed physicians, physician assistants, nurse practitioners, mental health professionals, and other licensed healthcare professionals made available through the Remedora platform. The applicable physician-owned professional corporation, professional association, medical group, or other licensed healthcare entity responsible for furnishing healthcare services is referred to in this Consent as the “Practice.”
Remedora Inc. (“Remedora”) provides technology and administrative infrastructure used by the Practice to facilitate telehealth services. Remedora is not a medical practice and does not independently diagnose, treat, prescribe for, or otherwise furnish professional medical services. All diagnoses, treatments, prescriptions, and other clinical decisions are made by licensed healthcare providers exercising independent professional judgment.
OUR HEALTHCARE PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES THROUGH THE PLATFORM. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL 911 OR GO TO THE NEAREST EMERGENCY DEPARTMENT.
BY CLICKING “I AGREE,” CHECKING A BOX INDICATING ACCEPTANCE, USING ANOTHER ELECTRONIC ACCEPTANCE METHOD PRESENTED THROUGH THE SERVICE, OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREED TO THIS CONSENT. IF YOU DO NOT AGREE, DO NOT SUBMIT AN INTAKE FORM, CREATE A PATIENT ACCOUNT, OR USE THE TELEHEALTH SERVICE.
CONSENT TO TELEHEALTH
Telehealth is a method of delivering healthcare services through electronic communications and related technologies. Telehealth may be used to facilitate medical evaluation, diagnosis, consultation, treatment, prescribing, patient education, care coordination, care management, and patient self-management.
The purpose of this Telehealth Consent Form (“Consent”) is to provide information about telehealth and obtain your informed consent to receive healthcare and, when applicable, mental or behavioral healthcare services from licensed healthcare providers (“Providers”) through technology and administrative services supplied by Remedora and made available through our website, applications, patient portal, or other connected digital interfaces (collectively, the “Platform”).
In this Consent, “you” and “your” refer to the patient receiving services. When services are requested for a minor or another person for whom consent may lawfully be provided, “you” and “your” also include the parent, legal guardian, personal representative, or other person legally authorized to provide consent on the patient’s behalf.
You are reviewing this Consent because you are requesting healthcare services from the Practice through the Platform. The Practice, rather than Remedora, is responsible for the professional healthcare services furnished to you. The identity of the Practice and your treating Provider will be disclosed during the intake or care process.
This Consent supplements, but does not replace or supersede, any applicable Terms of Use, Privacy Policy, Notice of Privacy Practices, financial policy, treatment-specific consent, or other notice furnished by the Practice, Remedora, or the organization through which you access the Platform.
By selecting “I consent to telehealth,” you acknowledge and agree that:
You have reviewed this Consent or had it explained to you.
You understand the potential benefits, risks, and limitations of telehealth.
You have had an opportunity to ask questions and receive answers.
You have had an opportunity to exercise any applicable right to refuse or withdraw consent.
You consent to receiving healthcare services from Providers who may be located at a location different from yours.
You understand that the Provider must be appropriately licensed or otherwise legally authorized to treat you in the jurisdiction where you are physically located when services are furnished.
For questions about your healthcare, medical records, privacy rights, or this Consent, contact the Practice or support team using the contact method displayed in your patient account or on the website through which you access the Platform.
TREATMENT-SPECIFIC CONSENT
By selecting “I consent to telehealth,” you understand and agree to the following:
I understand that telehealth encounters may be conducted using video, audio, telephone, secure messaging, store-and-forward communications, asynchronous questionnaires, remote monitoring, or other electronic communications. My Provider may not be physically present in the same room as me.
I authorize the Practice and my Providers to obtain, import, access, review, and use medical information reasonably necessary to evaluate and treat me, including my medical history, medication list, prescription history, laboratory results, allergies, and other relevant records, as permitted by law.
I understand that the Platform may be used to collect and transmit information to my Provider, but the Platform does not make clinical decisions. Diagnosis, treatment, prescribing, and other clinical decisions remain the responsibility of my Provider.
I understand that Remedora provides technology and administrative infrastructure supporting the Platform. Remedora is not my healthcare provider and does not control or interfere with my Provider’s independent professional judgment.
I agree to participate in telehealth encounters from a reasonably private location. I understand that my Provider will take reasonable measures to protect the privacy of the encounter. If another person is present for technical, translation, clinical, training, or other assistance, I will be informed of that person’s presence and role when required by law and given an opportunity to object or consent where applicable.
I understand that telehealth technology presents risks, including interruptions, delays, equipment failures, recording failures, incomplete or lost transmissions, unauthorized access, data-processing errors, inaccurate information, artificial-intelligence errors, ambient-listening inaccuracies, or other technical difficulties. Either my Provider or I may discontinue an encounter if the connection or technology is inadequate for the safe delivery of care.
I understand that artificial intelligence or automated tools may be used for administrative or clinical-support purposes, including transcription, documentation, summarization, workflow assistance, analysis of medical information, quality assurance, or clinical decision support. These tools are intended to support—not replace—the professional judgment of my Provider. My Provider remains responsible for reviewing clinically relevant outputs before relying on them to make clinical decisions.
I understand that artificial-intelligence systems may process information supplied during my telehealth encounter, including my voice, image, medical information, and information contained in my records. Such processing may occur during or after the encounter and will be subject to applicable privacy laws and the Practice’s privacy and security policies.
I may ask my Provider whether artificial-intelligence or automated technology is being used in connection with my care. Where reasonably feasible and permitted by the Practice’s policies, I may request that such technology not be used for certain aspects of my care.
When required by applicable law, I will be notified before audio, video, or ambient-listening technology records or captures an encounter. Any recording will require the consent mandated by applicable law. I may ask whether recording or ambient-listening technology is being used and may request that it be disabled where reasonably feasible and consistent with applicable law and the Practice’s policies.
I understand that recordings, if made, may be used for clinical documentation, care coordination, quality assurance, compliance, or training where permitted by law. Recordings will be retained and protected according to applicable law and the Practice’s retention and privacy policies.
I understand that my Provider may be a physician, nurse practitioner, physician assistant, mental health professional, or another appropriately licensed healthcare professional, depending on my location and healthcare needs.
I understand that I may seek an in-person evaluation instead of receiving care through telehealth. I am voluntarily choosing to receive services through telehealth.
I understand that my Provider may not have access to all of my medical records and cannot perform every examination or diagnostic procedure available during an in-person visit. These limitations could affect the Provider’s ability to diagnose or treat my condition and could result in an adverse outcome, including an undetected condition, adverse drug interaction, or allergic reaction.
I understand that the technology used to deliver care may contain defects or errors that could limit functionality, produce an incorrect result, make the technology temporarily unavailable, or cause information to be corrupted or lost.
I understand that healthcare delivered through telehealth is an evolving field. Technology used in my care may include features or uses not specifically described in this Consent, subject to applicable law and any additional consent legally required.
I understand that no benefit, outcome, cure, improvement, prescription, laboratory result, diagnosis, or other specific result is promised or guaranteed. My condition may not improve and, in some cases, may become worse.
I understand that telehealth may not be appropriate for every condition. My Provider may determine that an in-person examination, diagnostic testing, emergency evaluation, specialist consultation, or another form of care is necessary.
I agree that information I provide will be accurate, complete, and truthful to the best of my knowledge. I will promptly correct information that I learn is inaccurate or incomplete.
I understand that my Provider may determine that telehealth is inappropriate for my symptoms, condition, or circumstances and may recommend in-person care, urgent care, emergency services, diagnostic testing, or another healthcare professional.
I understand that submitting an intake form, requesting treatment, paying for a service, or completing a telehealth encounter does not guarantee that I will receive a prescription. Prescribing decisions are made solely by a licensed Provider based on independent professional judgment and applicable law.
I understand that there is no guarantee regarding the effectiveness or results of any prescription or telehealth encounter.
I understand that I may use a pharmacy or diagnostic laboratory of my choice unless a lawful limitation applies or I voluntarily select another option.
I understand that I am responsible for charges disclosed to me and for amounts not paid by an insurer or other third-party payer, subject to applicable law and the Practice’s financial policies.
I understand that neither the Platform nor its Providers is intended to address medical emergencies. If an emergency arises, my Provider may direct me to call 911, contact emergency medical services, or go to an emergency department.
If I am consenting for a minor or another person, I represent that I have the legal authority to consent to the requested evaluation, treatment, prescription, laboratory order, or other healthcare service on that person’s behalf.
I understand that I may withdraw my consent to telehealth prospectively by notifying the Practice. Withdrawal will not affect services already furnished or actions already taken in reliance on my consent and may prevent the Practice from continuing to furnish services through telehealth.
AUTHORIZATION TO USE AND DISCLOSE MEDICAL INFORMATION
I authorize the Practice and its Providers to use and disclose my protected health information as permitted or required by law for treatment, payment, healthcare operations, care coordination, prescribing, pharmacy fulfillment, laboratory services, patient support, and operation of the Platform.
I understand that Remedora and other service providers may receive or process protected health information on behalf of the Practice when necessary to provide technology, administrative, support, payment, prescribing, fulfillment, or related services. Such information must be handled in accordance with applicable privacy laws and contractual obligations.
When a separate authorization is required by law for a particular disclosure, the Practice will request that authorization separately or provide the disclosures required for a legally valid authorization.
I understand that:
Information disclosed to a recipient that is not subject to HIPAA or another applicable confidentiality law may no longer be protected by that law and could potentially be redisclosed.
I may decline an optional authorization. Except where permitted by law, declining an optional authorization will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits.
I may request access to or a copy of my medical records, subject to applicable law.
I may revoke an authorization in writing by contacting the Practice through the contact information displayed in my patient account or the website through which I access the Platform. Revocation will not affect actions already taken in reliance on the authorization.
If I accessed the Platform through a health brand, employer, benefits provider, or other program sponsor (“Program Partner”), information may be shared with that Program Partner only as permitted by applicable law and the relevant privacy notices or authorizations. Clinical information will not be disclosed to a Program Partner merely for marketing or engagement reporting unless the disclosure is legally permitted and appropriately authorized.
ADDITIONAL TREATMENT-SPECIFIC CONSENT: COMPOUNDED MEDICATIONS
This section applies if a Provider prescribes a compounded medication.
I understand that compounded medications are not approved by the United States Food and Drug Administration (“FDA”). The FDA does not review compounded medications for safety, effectiveness, quality, or manufacturing consistency before they are marketed.
I understand that a compounded medication may be prescribed when my Provider determines that it is clinically appropriate for my individual needs.
I understand that compounded medications may present risks that differ from FDA-approved medications, including risks related to potency, sterility, stability, contamination, dosing, consistency, inactive ingredients, and the availability of safety and effectiveness information.
I understand that a compounding pharmacy is subject to applicable state and federal requirements, but such regulation does not constitute FDA approval of a compounded medication.
I understand that an FDA-approved medication may be available to treat the same or a similar condition. I may ask my Provider about approved alternatives, their risks and benefits, and why a compounded medication is being recommended.
I understand that no representation or guarantee has been made regarding the safety, effectiveness, availability, or results of a compounded medication.
I agree to follow the dosing, storage, administration, monitoring, and disposal instructions furnished by my Provider or pharmacy.
I will promptly report unexpected symptoms, adverse reactions, medication errors, or concerns to my Provider. For a severe or life-threatening reaction, I will call 911 or seek immediate emergency care.
Medication-specific safety information and instructions may be provided through the website, patient portal, intake process, pharmacy materials, product packaging, or other documentation associated with the prescribed medication.
ADDITIONAL TREATMENT-SPECIFIC CONSENT: TELETHERAPY
This section applies if I receive a telehealth consultation related to mental or behavioral health.
I understand that teletherapy involves communicating mental or behavioral health information to a Provider through telehealth technology. Teletherapy has purposes similar to in-person therapy but may be experienced differently because the Provider and patient are in separate locations and technology is used to conduct the session.
I understand and agree that:
I may withhold or withdraw consent for teletherapy at any time, subject to applicable law. Withdrawal will not affect care already furnished.
The laws protecting the confidentiality of medical and mental health information generally apply to teletherapy.
Information disclosed during teletherapy is generally confidential, but exceptions may apply, including mandatory reporting of suspected abuse or neglect, a serious threat of harm to myself or another person, certain emergencies, court orders, or circumstances in which I place my mental or emotional condition at issue in a legal proceeding.
Teletherapy may not be as complete or appropriate as face-to-face services for every condition. If my Provider believes another form or level of care would be more appropriate, I may be referred to an in-person Provider, specialist, crisis service, or another qualified professional.
Teletherapy may benefit me, but no result or improvement is guaranteed. My condition may not improve and, in some circumstances, may become worse.
Teletherapy is not intended to address emergencies. If I am experiencing suicidal thoughts, intend to harm myself or another person, or believe I am in immediate danger, I will call 911 or go to the nearest emergency department. In the United States, I may also call or text 988 to reach the Suicide & Crisis Lifeline.
A person actively at risk of harming themselves or another person may not be appropriate for routine teletherapy and may be referred to a higher or more immediate level of care.
Personally identifiable images or information from a teletherapy interaction will not be disclosed to researchers or other unrelated entities without authorization unless otherwise permitted or required by law.
My Provider may contact my emergency contact or appropriate authorities when reasonably necessary to respond to an emergency or serious safety concern.
I agree to provide my physical location at the beginning of a teletherapy session when requested and to provide accurate emergency-contact information.
ADDITIONAL TREATMENT-SPECIFIC CONSENT: HIV TESTING
This section applies if I receive services related to Human Immunodeficiency Virus (“HIV”) testing.
HIV is the virus that can cause acquired immunodeficiency syndrome (“AIDS”). HIV may be transmitted through certain sexual contact, exposure to infected blood or shared needles, and from a pregnant or breastfeeding person to an infant.
Different HIV tests may detect HIV antibodies, antigens, or the virus itself. The appropriate specimen and testing method may vary. A preliminary positive or reactive result may require confirmatory testing. A confirmed positive result means that HIV infection was detected; it does not by itself mean that the person has AIDS.
A negative result generally means HIV was not detected by that test. However, testing too soon after a potential exposure can produce a negative result during the test’s window period. My Provider may recommend repeat testing based on the timing and nature of a potential exposure.
HIV testing is voluntary unless otherwise permitted or required by law. I may decline testing. Testing furnished through the Platform may not be anonymous. If I want anonymous testing, I may seek an anonymous testing location through a local or state health department or another authorized testing program.
Federal and state laws protect the confidentiality of HIV-related information. Results may nevertheless be disclosed when permitted or required by law, including reporting to appropriate public health authorities.
ADDITIONAL TREATMENT-SPECIFIC CONSENT: WEIGHT MANAGEMENT
I understand that weight-management treatment may involve lifestyle recommendations, laboratory testing, nutritional guidance, prescription medication, compounded medication, or referral to another healthcare professional.
I understand that:
Rapid or excessive weight loss may cause serious health problems.
I should disclose my complete medical history, medications, supplements, allergies, pregnancy status, and relevant personal or family history before beginning treatment.
Prescription medication is not a substitute for appropriate nutrition, physical activity, monitoring, and other lifestyle measures recommended by my Provider.
Weight-management medications may cause serious side effects and may not be appropriate for every patient.
Results vary, and no amount or rate of weight loss is guaranteed.
Weight may be regained after treatment is stopped.
I must follow my Provider’s instructions regarding dosing, monitoring, laboratory testing, follow-up care, and when to seek urgent or emergency assistance.
Florida Weight-Loss Consumer Bill of Rights
WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS. RAPID WEIGHT LOSS IS WEIGHT LOSS OF MORE THAN 1½ TO 2 POUNDS PER WEEK OR MORE THAN 1 PERCENT OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT-LOSS PROGRAM.
CONSULT YOUR PERSONAL PHYSICIAN BEFORE STARTING ANY WEIGHT-LOSS PROGRAM.
ONLY PERMANENT LIFESTYLE CHANGES, SUCH AS MAKING HEALTHFUL FOOD CHOICES AND INCREASING PHYSICAL ACTIVITY, PROMOTE LONG-TERM WEIGHT LOSS.
QUALIFICATIONS OF THIS PROVIDER ARE AVAILABLE UPON REQUEST.
YOU HAVE THE RIGHT TO:
Ask questions about the potential health risks of the program and its nutritional content, psychological support, and educational components.
Receive an itemized statement of the actual or estimated price of the weight-loss program, including additional products, services, supplements, examinations, and laboratory tests.
Know the actual or estimated duration of the program.
Know the name, address, and qualifications of the dietitian or nutritionist who reviewed and approved the weight-loss program when required by Florida law.
New York Weight-Loss and Dieting Information
WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS. RAPID WEIGHT LOSS IS WEIGHT LOSS OF MORE THAN 1½ TO 2 POUNDS PER WEEK OR MORE THAN 1 PERCENT OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT-LOSS PROGRAM.
Consult your physician before starting a weight-loss program or using diet medications or formulas.
Long-term weight control is the safest and most important goal of a diet program. Permanent lifestyle changes, including nutritious food choices, calorie control, and increased physical activity, help promote long-term weight management.
You may ask the person providing or selling weight-loss advice, products, medications, or formulas about that person’s qualifications and training in nutrition and health.
You have the right to:
Ask questions about the potential health risks, nutritional content, psychological-support components, and educational components of the program or product.
Know the price of treatment, including additional products, services, supplements, and laboratory tests.
Know the recommended duration of the program.
ADDITIONAL TREATMENT-SPECIFIC CONSENT: GENETIC TESTING
This section applies if I am offered genetic testing.
I understand that genetic testing can be complex and that the testing method, specimen requirements, accuracy, limitations, and significance of the results will vary depending on the test and condition being evaluated.
I understand that genetic testing may reveal information about my health, biological relationships, inherited risks, carrier status, or the potential health risks of family members. Results may be uncertain, inconclusive, or subject to reinterpretation as scientific knowledge changes.
Before completing genetic testing, I will receive information about the specific test and have an opportunity to ask questions. When appropriate, I may be offered or referred for professional genetic counseling to help me understand the potential risks, benefits, limitations, and consequences of testing.
ADDITIONAL TREATMENT-SPECIFIC CONSENT: PEPTIDE THERAPY
This section applies if I receive a telehealth consultation related to peptide therapy.
I understand that peptides are chains of amino acids that may act as signaling molecules in the body. Different peptides have different proposed uses, mechanisms, risks, and levels of supporting scientific evidence.
I understand that certain peptide products or proposed uses may not be approved by the FDA. Products that are not FDA-approved have not been reviewed by the FDA for safety, effectiveness, quality, dosage, or suitability for a particular medical condition.
I understand that:
The potential benefits and risks depend on the specific product, dose, route of administration, my medical history, and other medications or supplements I use.
Potential risks may include injection-site pain, redness, swelling, infection, allergic reaction, headache, dizziness, flushing, nausea, changes in appetite, heart palpitations, changes in blood sugar, drug interactions, and other known or unknown effects.
Some risks may be serious, permanent, or currently unknown.
Certain products may be inappropriate for patients with cancer, a history of cancer, pregnancy, breastfeeding, endocrine disorders, cardiovascular conditions, or other medical conditions.
My Provider will evaluate whether a proposed treatment is appropriate but cannot eliminate or guarantee against adverse reactions.
I must disclose my complete medical history, allergies, prior reactions, current medications, supplements, pregnancy status, and relevant health conditions.
I will receive information about the specific therapy prescribed to me, including material risks, administration instructions, monitoring requirements, and alternatives.
No particular therapeutic result is guaranteed.
My health insurer may classify certain peptide treatments as experimental or investigational and may deny reimbursement.
Receiving peptide therapy does not prevent me from seeking other treatment or obtaining a second opinion.
I acknowledge that I have had an opportunity to ask questions about the proposed therapy and that I may decline treatment.
LABORATORY PRODUCTS AND SERVICES
Certain healthcare services may require an at-home diagnostic test or testing performed by a third-party laboratory. Laboratory products and services are provided by independent laboratories or testing providers.
The Practice, Remedora, and the organization through which I access the Platform cannot guarantee the accuracy, reliability, availability, or timeliness of an independently provided laboratory test. Tests may produce false-positive, false-negative, incomplete, delayed, or inconclusive results. A specimen problem, shipping delay, test failure, or other defect could affect my Provider’s ability to diagnose or treat a medical condition.
I understand that laboratory results must be interpreted by a qualified Provider in the context of my history, symptoms, examination, and other clinically relevant information.
AUTHORIZATION TO BILL INSURANCE AND ASSIGNMENT OF BENEFITS
By selecting “I accept,” I certify that the insurance and eligibility information I have provided is accurate and complete to the best of my knowledge.
If the Practice accepts insurance for services furnished to me, I authorize the Practice to submit claims and related information to my insurer or other third-party payer. I authorize the payer to make payment directly to the Practice when permitted by my benefit plan and applicable law.
I authorize the Practice, its billing service providers, and my payer to use and disclose healthcare and financial information as reasonably necessary to determine eligibility, obtain authorization, process claims, coordinate benefits, collect payment, and conduct related payment activities.
I understand that I remain financially responsible for applicable deductibles, copayments, coinsurance, non-covered services, and other balances, subject to applicable law and the financial terms disclosed to me. Services furnished by independent laboratories, pharmacies, imaging providers, pathologists, or other third parties may be billed separately.
CONSENT TO TELEPHONE, TEXT, AND EMAIL COMMUNICATIONS
By selecting “I accept,” I authorize the Practice, the organization through which I access the Platform, Remedora acting on their behalf, and their authorized service providers to contact me at the telephone number and email address I provide for purposes related to:
Appointment and treatment reminders;
Patient-account and service notifications;
Prescription, pharmacy, laboratory, fulfillment, or shipping updates;
Requests for information necessary to provide services;
Patient-support communications;
Patient feedback requests; and
General health and wellness information where legally permitted.
I understand that:
Communications may be sent using automated dialing, messaging, email, workflow, or artificial-intelligence-assisted systems.
Message frequency may vary.
Standard telephone, messaging, and data rates may apply.
Consent to receive marketing communications is not a condition of purchasing goods or receiving healthcare services.
I may withdraw consent to nonessential communications using the unsubscribe or opt-out method included in the communication or by contacting support.
I may reply STOP to opt out of eligible SMS messages and HELP for assistance when those commands are supported.
Unencrypted telephone calls, text messages, and emails may present privacy and security risks, including access by someone who has access to my device, telephone account, or email account.
Opting out of marketing or general informational communications will not prevent legally permitted communications necessary for treatment, safety, account administration, transactions I requested, or fulfillment of services.
ADDITIONAL STATE-SPECIFIC DISCLOSURES
The following provisions apply when required by the law of the state where I am physically located when receiving telehealth services.
Alaska
I understand that my primary care provider may obtain a copy of the records from my telehealth encounter as permitted by applicable law.
California
The Open Payments database is a federal tool used to search payments made by drug and medical-device companies to physicians and teaching hospitals. The database is available at:
https://openpaymentsdata.cms.gov
The federal Physician Payments Sunshine Act requires certain information about payments and other transfers of value from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals to be made publicly available.
Treatment Records
I understand that, where permitted or required by law, my primary care provider or another treating healthcare professional may obtain a copy of my telehealth treatment records with my authorization.
I may request assistance transmitting my records to another healthcare professional by contacting support through my patient account or the website through which I access the Platform. I may be required to complete an authorization and provide sufficient information to identify the intended recipient securely.
ELECTRONIC ACKNOWLEDGMENT AND SIGNATURE
By selecting “I agree,” “I accept,” “I consent to telehealth,” or another substantially similar acceptance option, I acknowledge and agree that:
I have read and understand this Consent.
I have had an opportunity to ask questions.
I voluntarily consent to receiving healthcare services through telehealth.
I consent to the uses and disclosures described above, subject to applicable law.
My electronic acceptance constitutes my legally binding electronic signature.
I may download, print, or request a copy of this Consent for my records.