Telehealth Consent

At WellnessLife MD, we deliver personalized healthcare through secure telehealth services, which may include video calls, phone consultations, and secure digital messaging. By participating in this program, you acknowledge and agree to the following:

1. Nature of Telehealth Services

I understand that telehealth allows me to receive healthcare services remotely using technology (e.g., internet, phone). This includes, but is not limited to, diagnosis, consultation, treatment planning, education, care management, and health coaching.

2. Providers & Setting

I understand that WellnessLife MD clinicians provide care via telehealth platforms and will not be physically present with me during appointments. I understand I may be seen through video, phone, or asynchronous (message-based) communication.

3. Risks and Limitations

I understand that telehealth carries potential risks such as technical failures, interruptions, delays, or unauthorized access. I acknowledge that either I or my provider may pause or discontinue the visit if the quality of the connection is inadequate.

4. Alternative to Telehealth

I understand that I have the right to seek in-person care instead of participating in telehealth. I choose to receive services through WellnessLife MD’s virtual model.

5. Privacy and Confidentiality

I agree to conduct my telehealth visits from a private location to protect my confidentiality. I understand my provider will also be in a private, secure setting. All communication is conducted through HIPAA-compliant platforms.

6. Minimum Commitment and Non-Refundable Fees

I understand that my initial payment to WellnessLife MD is non-refundable due to services rendered and expenses incurred immediately upon my enrollment including account setup, clinical coordination and prepaid labwork orders. However, if WellnessLife MD staff or affiliated services determine that the appointment or membership is not medically appropriate, a refund will be provided.

7. Payment Responsibility

I understand that I, and only I, am responsible for payment of any amounts due and owing resulting from my Telehealth subscription.

8. Cancellation Policy

I understand that subscription cancellations must be submitted in writing at least 15 days prior to the next billing cycle. Requests submitted less than 15 days before the billing date will incur one final monthly charge.

9. No Guarantee of Prescriptions

I understand that enrolling in the WellnessLife MD program does not guarantee a prescription will be provided.

10. Communication Channels

I understand that communication with my provider will primarily occur through the secure WellnessLife MD secure video conference, phone consultation, SMS and Email channels.

11. Emergencies

I understand that WellnessLife MD does not manage medical emergencies. If I am experiencing an emergency, I should dial 911 or go to the nearest emergency room. My provider may also advise me to seek emergency care if my condition requires it.

12. Personal Information & Security

I understand that I may be asked to provide personal identifiers such as a photo ID and Social Security number, similar to any in-person medical visit. I acknowledge that WellnessLife MD uses secure, HIPAA-compliant systems to safeguard this information.

Acknowledgement

By checking the box or signing below, I acknowledge that:

• I have read and understood this consent form.
• I have had the opportunity to ask questions, and my questions have been answered.
• I understand the risks and benefits of receiving care via telehealth.
• I consent to receive care from WellnessLife MD through telehealth services.