Telehealth Informed Consent

01What telehealth means

I consent to appropriate health services through the remote methods explained to me. These may include live video, telephone when permitted and clinically appropriate, secure messages, and electronic exchange of records. Telehealth may be used for evaluation, consultation, laboratory discussion, treatment planning, and follow-up. Not every service or communication method is available or appropriate in every circumstance.

02Benefits limitations and alternatives

Potential benefits include convenient access, less travel, and continuity of care. Limitations include an incomplete physical examination, poor quality or incomplete information, connection failure, delays, and privacy or security risks. These limitations may affect assessment or treatment. My clinician may require in person evaluation, local testing, specialist referral, or emergency care.

I may ask questions, decline telehealth, or withdraw consent for future telehealth at any time by telling the practice. We will discuss available alternatives and appropriate continuity arrangements. An in person HaadMD visit may not be available in my location. Withdrawal does not erase prior care or records, and its financial effect is governed by the separate lawful program agreement rather than automatic forfeiture.

03Identity location and participants

At each encounter I will confirm my identity, current physical location, and reliable callback number, including when I travel. Care depends on the clinician's legal authority at that location. The clinician will identify themselves, their role, and participating personnel. I will identify anyone present with me and choose a setting that protects my privacy. The practice provides communication assistance and reasonable accommodations when required by applicable law and arranges appropriate participation by authorized representatives.

04Interruptions emergencies and follow-up

We will agree on a callback method before the visit. If the connection fails, we will try that method and determine whether to resume, reschedule, or arrange other care. If I cannot reconnect and believe I need prompt attention, I will use the instructions supplied by the practice or seek appropriate local care.

For an emergency I will call 911 or seek emergency care. I will not wait for a response to portal messages, diet or exercise logs, lab uploads, or weekly check-ins. These channels are not continuously monitored. The practice's routine support hours, expected response time, and earlier attention route are stated in my Enrollment Summary. I will receive appropriate follow-up instructions after a clinical encounter.

05Privacy records and communication choices

Information from telehealth may become part of my medical record. The Notice of Privacy Practices and applicable law govern its use and disclosure. I retain applicable rights to access records, request amendments, and request confidential communication. Ordinary email and text may carry privacy risks; detailed clinical matters should use the approved clinical channel. I may discuss communication preferences with the practice.

This consent does not authorize recording, third party transcription of the encounter, publicity, testimonials, or unrelated research or model training. Optional recording and AI transcription require the separate choice presented before capture begins. Telehealth can proceed using ordinary clinician documentation when clinically appropriate if I decline that option.

06Clinical judgment and consent

Telehealth does not guarantee a prescription, a particular treatment, or a result, and does not reduce the professional standard of care. Medication, hormone, compounded therapy, procedure, or other intervention specific risks and alternatives must be discussed as appropriate. General telehealth consent does not replace those discussions.

I have read this consent or had it explained to me, had an opportunity to ask questions, and received answers I understand. I voluntarily consent to telehealth as described. I may obtain a copy.

Patient or authorized representative signature: Date and time:

Representative authority if applicable:

Clinician or staff documentation of consent and questions addressed:

07Encounter details and optional coordination

Encounter date: Patient physical address and state:

Callback number: Agreed interruption plan:

Clinician identity degree specialty and practice location disclosed:

Other participants and roles: Modality:

Primary care clinician and contact if any:

Optional coordination choice: I request appropriate information be sent to my primary care clinician. I decline this optional sharing. Separate consent requirements and other lawful disclosures remain governed by applicable law and the Notice of Privacy Practices.

A decision not to share with a primary care clinician is recorded; it is not silently treated as consent. Applicable state notices and required follow-up arrangements are provided by the practice.