Medical & Informed Consent for Telehealth

Last updated: 08/2026
By enrolling in care with ThriveWell Men’s Health Clinic, you acknowledge and agree to
the following:
4.1 Nature of Telehealth Telehealth involves the use of electronic communication to
enable healthcare providers at a distance to evaluate, diagnose, and treat patients
without an in-person visit. I understand that telehealth may involve electronic
transmission of my personal health information, and that this information could be
intercepted, though ThriveWell uses reasonable safeguards to protect it.
4.2 Benefits & Risks: I understand the potential benefits of telehealth, including
improved access to care and convenience. I also understand the potential risks,
including but not limited to: limitations of a remote physical exam, technical failures, and
the possibility that the provider may determine telehealth is not appropriate for my
condition and refer me to in-person care.
4.3 Provider Licensure: I understand my provider is licensed to practice in the state
where I am physically located at the time of my visit, and that I must promptly inform
ThriveWell if I am not located in a state where we are licensed.
4.4 Not Emergency Care: I understand telehealth services are not appropriate for
emergency medical conditions, and that in an emergency I should call 911 or go to the
nearest emergency room.
4.5 Prescribing I understand that prescribing decisions, including for controlled
substances such as testosterone, are made at the sole clinical discretion of my provider
based on my medical history, examination, and applicable lab work, and in compliance
with federal and state law governing telehealth prescribing of controlled substances.
4.6 Confidentiality: My health information shared during telehealth visits is subject to
the same confidentiality protections as an in-person visit, as described in ThriveWell’s
Notice of Privacy Practices.
4.7 Right to Withdraw: I understand that my consent to telehealth is voluntary and I
may withdraw consent at any time without affecting my right to future care.
4.8 Patient Acknowledgment: By signing/checking the box at intake, I acknowledge
that I have read and understood this consent, had the opportunity to ask questions, and
voluntarily agree to receive care via telehealth from ThriveWell Men’s Health Clinic.