Telehealth Informed Consent

Last updated: [INSERT DATE] · Draft — pending legal review

1. What Telehealth Is

Telehealth is the delivery of health care services using electronic communications — such as secure messaging, questionnaires, photos, audio, and video — where the patient and the health care provider are not in the same physical location. Your provider may use telehealth to evaluate your health, make a diagnosis, and, when clinically appropriate, prescribe treatment.

2. Expected Benefits

• Access to licensed medical care without traveling to an office.
• Convenient follow-up and ongoing communication with your care team.

3. Possible Risks

• Your provider does not perform an in-person physical examination, and must rely on the information you provide. Incomplete or inaccurate information can affect your care.
• In rare cases, technical failures may delay evaluation or communication.
• Telehealth may not be appropriate for every condition; your provider may determine you need in-person care and refer you accordingly.
• [State-specific risk disclosures — counsel to complete.]

4. Not for Emergencies

Telehealth services are not appropriate for medical emergencies. If you believe you are experiencing an emergency, call 911 or go to the nearest emergency room immediately.

5. Your Rights

• You may withhold or withdraw consent to telehealth services at any time without affecting your right to future care.
• You may ask questions about the technology and services before consenting.
• The laws that protect the confidentiality of your medical information apply to telehealth. See our Notice of Privacy Practices.
• [State-specific patient rights — counsel to complete.]

6. Prescriptions

No prescription is guaranteed. A licensed provider will evaluate your information and determine, in their independent medical judgment, whether treatment is appropriate for you. Compounded medications are prepared by licensed pharmacies and are not reviewed by the FDA for safety or effectiveness.

7. Consent

By checking the consent box or proceeding with the VIV RX intake process, you acknowledge that you have read and understood this document, and you consent to receive health care services via telehealth from providers made available through the VIV RX platform, operated by Viv Health, Inc.

Questions: support@vivrx.com.