Telehealth Consent

Effective Date: June 18, 2024

Important: If you are experiencing a life-threatening situation, such as contemplating suicide, please call 911 or the 988 Suicide & Crisis Lifeline at 988 immediately.

Purpose

This consent form provides information about telehealth and seeks your informed consent to use telehealth for healthcare services provided by physicians, physician assistants, and nurse practitioners ("Providers") through Victory Wellness Online's online platform ("Service").

Use of Telehealth

Telehealth delivers healthcare services via electronic communications, information technology, or other means when the patient and provider are not in the same location. Telehealth can be used for diagnosis, treatment, follow-up, and patient education. This may include:

• Electronic transmission of medical records, images, personal health information, or other data.
• Interactions via audio, video, and data communications (e.g., messaging or email).
• Use of output data from medical devices, sound, and video files.

Anticipated Benefits

• Easier and more efficient access to medical care and services.
• Convenience of obtaining care at times that suit you.
• Ability to interact with Providers without the need for an in-office appointment.

Potential Risks

• Limited quality, accuracy, or effectiveness of services.
• Technology issues such as bugs or errors that may limit functionality or produce erroneous results.
• Failures in technology that could affect your Provider's ability to diagnose or treat.
• Inability to conduct certain tests or assess vital signs in person.
• Delays in treatment due to technology or Provider unavailability.
• Potential breaches of privacy due to electronic system failures.
• Regulatory limitations on certain prescriptions or treatments.

Life-Threatening and Emergency Situations

For life-threatening emergencies, such as contemplating suicide, call 911 or the 988 Suicide & Crisis Lifeline at 988. For urgent care, telehealth may not be appropriate. Seek care at an emergency room or other urgent care facility.

Data Privacy and Protection

The Service uses network and software security protocols to protect your information. Your personal and protected health information will not be disclosed without your consent, except as required by law.

Your Acknowledgments

By using our services, you acknowledge:

• Healthcare services via the Service will be provided through telehealth.
• Your Provider may be a nurse practitioner or physician assistant, not always a physician.
• No guarantees of specific results from telehealth or related laboratory testing.
• Telehealth may not be suitable for every condition and may require alternative or emergency care.
• You can withdraw your consent for telehealth at any time in writing.

Pharmacy Orders and Prescriptions

Victory Wellness Online partners with pharmacies to fulfill orders. Prescriptions can be filled and transferred between partner pharmacies. You must cover the full cost of the Service, including prescriptions, and will not submit claims to Medicare, federal payors, or insurers.

Medical Concerns

If you have concerns about a medical professional, contact the Medical Board in your state.

Contact

Questions? Email us at [email protected].