Telehealth Informed Consent

Last Updated: August 13, 2026

TELEHEALTH IS NOT APPROPRIATE FOR MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL OR PSYCHIATRIC EMERGENCY, CALL 9-1-1 OR GO TO THE NEAREST EMERGENCY DEPARTMENT. DO NOT RELY ON TELEHEALTH, TEXT MESSAGING, EMAIL, OR PATIENT MESSAGING FOR EMERGENCY CARE.

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Introduction

Flexup Wellness PLLC (“Flexup Wellness”) provides healthcare through both in-person and telehealth appointments.

Telehealth is the delivery of healthcare services using electronic communication technologies when the patient and healthcare provider are in different locations. Telehealth may include secure video, telephone, electronic messaging, exchange of medical information, questionnaires, photographs, laboratory results, health-monitoring data, and other electronic technologies used to support evaluation, diagnosis, treatment, education, care management, and follow-up.

This Telehealth Informed Consent explains the potential benefits, risks, limitations, and alternatives associated with receiving healthcare through telehealth.

By consenting to telehealth, I acknowledge that I have read and understand this document, have had the opportunity to ask questions, and voluntarily consent to receiving healthcare from Flexup Wellness through telehealth when clinically appropriate.

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Nature of Telehealth

I understand that during a telehealth appointment, my Flexup Wellness provider and I will be in different physical locations.

I understand that telehealth may be used for healthcare services including evaluation, follow-up care, review of laboratory results, medication management, nutrition and lifestyle counseling, metabolic health, gastrointestinal health, hormonal health, mental and behavioral health management, and other services within the scope of Flexup Wellness.

Depending upon the circumstances, telehealth may involve:

• Secure video conferencing;

• Telephone communication;

• Secure electronic messaging;

• Electronic questionnaires and forms;

• Review and exchange of medical records;

• Laboratory and diagnostic information;

• Photographs or other information I provide;

• Health-monitoring information; and

• Other electronic information reasonably necessary for my care.

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Benefits of Telehealth

I understand that potential benefits of telehealth may include:

• Improved access to healthcare;

• Reduced travel;

• Greater scheduling convenience;

• Easier follow-up and continuity of care;

• More timely review of certain health concerns or results; and

• The ability to receive appropriate healthcare while remaining at another location.

I understand that these potential benefits are not guaranteed.

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Risks and Limitations of Telehealth

I understand that telehealth has limitations compared with an in-person medical evaluation.

Potential risks and limitations include:

• My provider may not be able to perform a complete physical examination;

• Certain physical findings may be difficult or impossible to evaluate remotely;

• Information available to my provider may be incomplete;

• Technical problems may interrupt or delay an appointment;

• Electronic communications may potentially be intercepted or accessed despite reasonable security precautions;

• Poor video, audio, internet connectivity, or device performance may affect the quality of the evaluation;

• A condition initially evaluated through telehealth may subsequently require an in-person examination, laboratory testing, imaging, specialist consultation, urgent care, or emergency evaluation; and

• Delays in diagnosis or treatment may occur if telehealth is inadequate for evaluating my condition.

I understand that no healthcare service, whether provided in person or through telehealth, can guarantee a particular diagnosis, treatment response, or outcome.

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In-Person Evaluation May Be Required

I understand that Flexup Wellness is a hybrid practice offering both telehealth and in-office care.

My provider may determine at any time that my condition cannot be safely or adequately evaluated or treated through telehealth.

If that occurs, I may be asked to schedule an in-person appointment, obtain a physical examination from another healthcare professional, complete laboratory or diagnostic testing, see a specialist, or seek urgent or emergency medical care.

I understand that my preference for telehealth does not require my provider to continue providing care remotely when the provider believes an in-person evaluation or another level of care is medically necessary.

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My Physical Location During Telehealth

I understand that healthcare laws and professional licensing requirements may depend upon where I am physically located at the time healthcare is provided.

I agree to accurately provide my physical location at the beginning of a telehealth encounter when requested.

I understand that Flexup Wellness may be unable to provide healthcare to me through telehealth if I am physically located in a jurisdiction where my provider is not legally authorized to practice.

If my location changes during an ongoing course of care, I agree to notify Flexup Wellness when relevant to receiving telehealth services.

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Privacy During Telehealth

Flexup Wellness takes reasonable steps to protect the privacy and confidentiality of telehealth encounters.

Flexup Wellness uses healthcare technology designed to support HIPAA-compliant clinical operations, including Malla for electronic medical records and Spruce Health for secure patient calls, text messaging, and communications.

I understand that reasonable safeguards are used to protect my health information but that no electronic communication technology can be guaranteed to be completely free from privacy or security risks.

I agree to take reasonable steps to protect my own privacy during telehealth appointments, including participating from a private location when reasonably possible and using devices and internet connections that I reasonably believe are secure.

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Other Individuals Present

I understand that I may choose to have another individual present during my telehealth appointment when appropriate.

If another individual is present with my provider for purposes such as clinical assistance, interpretation, training, or technical support, I will be informed when required and given an opportunity to ask questions or object when appropriate.

I understand that I am responsible for informing my provider if another person is present with me during an encounter when that person's presence may affect the confidentiality of the visit or my care.

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Electronic Medical Records and Health Information

I consent to Flexup Wellness accessing, creating, maintaining, and reviewing health information reasonably necessary to provide my care.

This may include medical history, medication and supplement information, prescription history when legally available, laboratory results, diagnostic information, prior medical records, clinical communications, and other information relevant to my healthcare.

I understand that my telehealth encounters and related communications may be documented in my medical record in the same manner as in-person healthcare.

My health information will be handled in accordance with applicable privacy laws and the Flexup Wellness Notice of Privacy Practices.

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Accuracy of Information

I agree to provide information that is accurate and complete to the best of my knowledge.

I understand that withholding relevant information or providing inaccurate information regarding my medical history, medications, supplements, allergies, symptoms, substance use, laboratory results, or other health information may interfere with my provider's ability to safely evaluate and treat me.

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Prescriptions and Treatment Recommendations

I understand that participating in a telehealth appointment does not guarantee that I will receive a prescription, laboratory order, supplement recommendation, Letter of Medical Necessity, referral, diagnostic test, or any particular treatment.

All clinical decisions are made by my Flexup Wellness provider using independent professional judgment and are subject to applicable laws, regulations, standards of care, and prescribing requirements.

My provider may require additional information, laboratory testing, medical records, an in-person examination, or another evaluation before recommending or prescribing a treatment.

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Pharmacies and Laboratories

When clinically appropriate, Flexup Wellness may electronically communicate prescriptions, laboratory orders, or other healthcare information to pharmacies, laboratories, or other healthcare organizations involved in my care.

I understand that I generally have the right to request a pharmacy or laboratory of my choice, subject to availability, clinical requirements, contractual limitations, and applicable law.

Independent pharmacies and laboratories may maintain their own privacy, billing, and operational policies.

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Mental and Behavioral Health

Telehealth may be used for mental or behavioral health evaluation and management when clinically appropriate and within the scope of services provided by Flexup Wellness.

I understand that certain psychiatric or behavioral health conditions may not be appropriate for telehealth management or may require additional evaluation, psychotherapy, specialty psychiatric treatment, emergency services, hospitalization, or another level of care.

I understand that confidentiality generally applies to mental and behavioral health information but may be subject to legally required or permitted exceptions, including circumstances involving suspected abuse or neglect, serious threats of harm, court orders, or other situations where disclosure is authorized or required by law.

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Emergencies and Urgent Conditions

I understand that Flexup Wellness does not provide emergency medical services through telehealth or electronic messaging.

Telehealth appointments, Spruce messages, text messages, voicemail, email, and website communications should not be relied upon for emergency care.

If I experience potentially serious symptoms such as severe chest pain, severe difficulty breathing, loss of consciousness, signs of stroke, severe allergic reaction, uncontrolled bleeding, suicidal intent, an immediate risk of harm to myself or another person, or another potentially life-threatening condition, I understand that I should call 9-1-1 or seek immediate emergency medical attention.

My Flexup Wellness provider may discontinue a telehealth encounter and direct me to emergency services, urgent care, an emergency department, or another healthcare facility when clinically appropriate.

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Technical Failure

I understand that a telehealth encounter may be interrupted because of internet failure, equipment malfunction, software problems, loss of audio or video, or other technical difficulties.

If technical problems prevent an adequate clinical evaluation, my provider may attempt another communication method, reschedule the appointment, recommend an in-person evaluation, or direct me to another appropriate healthcare resource.

I understand that technical failure does not obligate my provider to continue an encounter when doing so would be clinically inappropriate or unsafe.

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Recording and AI assistance​

Recording and AI-Assisted Documentation
I understand that Flexup Wellness may use AI-assisted clinical documentation technology during telehealth encounters only when I have separately consented to its use. The use of such technology is governed by the Flexup Wellness AI-Assisted Clinical Documentation Consent.

Except for AI-assisted documentation to which I have consented or as otherwise specifically disclosed and authorized, Flexup Wellness will not intentionally audio- or video-record my telehealth encounter without appropriate notice and consent.

I agree not to audio-record, video-record, photograph, livestream, or otherwise reproduce a telehealth encounter without the prior consent of my provider and any other individuals participating in the encounter.

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Fees and Payment

I understand that I am responsible for fees associated with telehealth services according to the applicable Flexup Wellness financial policies, program terms, or Partnership agreement.

Telehealth does not change my financial responsibility for healthcare services.

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Alternative to Telehealth

I understand that telehealth is not my only potential option for receiving healthcare.

Flexup Wellness provides in-office appointments, and I may discuss whether an in-person appointment is appropriate or available.

I understand that choosing not to receive care through telehealth does not prevent me from requesting in-person care from Flexup Wellness, although availability and the clinical appropriateness of particular services may vary.

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Right to Withdraw Consent

I understand that my participation in telehealth is voluntary.

I may withdraw my consent to future telehealth services and request in-person care instead. Withdrawal of consent will not affect the validity of healthcare already provided or actions already taken based upon my previous consent.

Withdrawal of telehealth consent does not guarantee that Flexup Wellness will be able to provide every requested service in person or continue a particular treatment when doing so would be clinically inappropriate.

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Consent

By selecting “I Consent to Telehealth,” signing electronically, or otherwise affirmatively indicating my consent:

I acknowledge that I have read and understand this Telehealth Informed Consent.

I understand the nature, benefits, risks, and limitations of receiving healthcare through telehealth.

I understand that telehealth may not be appropriate for every medical or behavioral health condition.

I understand that my provider may require an in-person evaluation or another level of care.

I have had the opportunity to ask questions regarding telehealth and have had those questions answered to my satisfaction.

I voluntarily consent to receiving healthcare services from Flexup Wellness PLLC through telehealth when my provider determines that telehealth is clinically and legally appropriate.

I Consent to Telehealth.

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