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Telehealth Consent
Effective date: [date] · Last updated: [date]
Please read this consent before your first visit. By checking the consent box, you agree to receive care through telehealth from licensed clinicians of [Medical group, P.C.].
1. What telehealth is
Telehealth means getting medical care from a clinician who is not in the same place as you, using secure online questionnaires, messaging, phone or video. Your clinician may review your information without a live visit, unless your state or your situation requires one.
2. Benefits and limits
Telehealth can make care faster and more convenient. It also has limits: your clinician can't perform a physical exam, and some conditions need in-person care. Your clinician may decide telehealth isn't right for you and refer you elsewhere.
Technology can fail. If a visit or message is interrupted, we'll help you reconnect or reschedule.
3. Your clinician
Your clinician is licensed in the state where you are located at the time of care. You can see your clinician's name and credentials, and verify their license, at any time.
4. Prescriptions
Your clinician decides whether a prescription is medically appropriate. Not every request results in a prescription. Prescriptions are sent to [Pharmacy partner] or another pharmacy you choose, where allowed.
5. Your responsibilities
Give complete and accurate information, including all medications and health conditions. Tell your care team about side effects or changes in your health. Follow up with in-person care when your clinician recommends it.
6. Privacy and security
Your information is protected as described in [Medical group, P.C.]'s Notice of Privacy Practices and Her Venus's Privacy Policy. Messaging and visits use secure, encrypted systems.
7. Emergencies
Telehealth through Her Venus is not for emergencies. Call 911 for a medical emergency. Call or text 988 for a mental health crisis.
8. Your consent
You understand the information above, have had the chance to ask questions, and consent to receive care through telehealth. You may withdraw this consent at any time by contacting [support@ email], which will end future telehealth care.
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Medical services are provided by independent licensed clinicians of [Medical group, P.C.]. Prescriptions are filled by [Pharmacy partner]. Her Venus is not a pharmacy and does not make medication. Compounded drugs are not FDA-approved. Not for emergencies: call 911, or call or text 988 for a mental health crisis.
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