Telehealth Informed Consent

This Telehealth Informed Consent ("Consent") applies to care you may receive from independent licensed providers affiliated with [AFFILIATED MEDICAL GROUP, P.C.] (the "Medical Group") through the CRUX platform at CruxBody.com. Please read it before proceeding with care.

1. What Telehealth Is

Telehealth is the delivery of health care services using secure electronic communications — such as questionnaires, secure messaging, audio, and/or video — when the provider and patient are in different locations. It may be used for evaluation, consultation, treatment recommendations, prescribing where appropriate, and follow-up.

2. Voluntary Consent

Your participation in telehealth is voluntary. You may withdraw your consent and discontinue telehealth services at any time without affecting your right to seek future care, and you may request an in-person provider instead.

3. Benefits

Potential benefits include improved access to care, convenience, and the ability to receive evaluation and follow-up without travel.

4. Risks and Limitations

You understand that telehealth has limitations, including:

• A provider may be unable to fully evaluate your condition without an in-person exam, and may determine that telehealth is not appropriate for you and recommend in-person care.
• Technical failures or transmission problems may delay or disrupt care.
• Despite reasonable safeguards, electronic transmission carries a small risk that information could be intercepted or accessed without authorization.
• A provider may decline to prescribe any particular treatment, including peptide or hormone therapies, based on independent clinical judgment, your history, lab results, and the laws of your state.

5. No Guarantee of Outcome; Not for Emergencies

No specific result is guaranteed. Telehealth is not appropriate for medical emergencies. If you have a medical emergency, call 911 or go to the nearest emergency room.

6. Eligibility and Honest Disclosure

You confirm that you are at least 18 years old, are physically located in a state where services are available, and will provide accurate, complete, and truthful information, including your identity, location, medical history, current medications, and any lab work requested. Incomplete or inaccurate information can compromise the safety and appropriateness of care.

7. Labs and Monitoring

Certain protocols require baseline and/or ongoing laboratory testing and follow-up evaluation. You agree to complete reasonably requested lab work and follow-up as a condition of continued care, and you understand that treatment may be paused or discontinued if monitoring is not completed.

8. Prescriptions and Pharmacy

If a provider determines a prescription is appropriate, it will be sent to a licensed pharmacy, including [COMPOUNDING PHARMACY PARTNER] where applicable, for dispensing and shipment. You are responsible for following all instructions for safe use, storage, and administration, and for reporting side effects to your provider.

9. Privacy of Telehealth Information

Your PHI created during telehealth is protected under HIPAA and the Medical Group's Notice of Privacy Practices. Please review that Notice for details.

10. Acknowledgement

By proceeding, you acknowledge that you have read and understood this Consent, that your questions have been answered to your satisfaction, and that you consent to receive care via telehealth under these terms.

[Capture: patient name, date, and affirmative acceptance (e.g., checkbox + typed name) at the point of intake. Retain a record of acceptance. Attorney to confirm state-specific consent requirements, including any separate consent for controlled substances if TRT is offered.]