Telehealth Consent and Disclosure Form

This form serves as your consent and acknowledgment for receiving medical care via telehealth services provided by Lifespanning. Telehealth involves the delivery of health care services using electronic communications, information technology, or other means between a patient at one location and a provider at another location.

1. Nature of the Telehealth Relationship

You understand that your relationship with Lifespanning is being conducted remotely, without in-person visits. This relationship is dependent upon accurate and complete communication from you, the patient. You agree to disclose all relevant health information, including but not limited to current medical conditions, medications, allergies, and any past medical history that may impact your treatment.

2. Limitations of Telehealth

You understand and acknowledge that Lifespanning  cannot perform physical exams or obtain vital signs during telehealth visits. Our providers rely solely on the information you provide and any lab work or diagnostics performed elsewhere. Inaccurate or incomplete information may result in misdiagnosis, inappropriate treatment, or other health risks.

3. Primary Care Responsibilities

You understand that Lifespanning  does not replace your primary care provider. We do not assume responsibility for comprehensive health management, including routine check-ups, vital signs, vaccinations, cancer screenings, or management of chronic diseases outside the scope of our services. You agree to maintain regular visits with your primary care physician and to keep them informed of any care or treatments received through Lifespanning .

4. Hold Harmless and Indemnification

By participating in telehealth treatment, you agree to hold harmless and indemnify Lifespanning, its owners, providers, and staff from any claims, damages, or liabilities arising from your treatment, except in cases of gross negligence or willful misconduct. You accept that responsibility for accurate communication and follow-up care lies in part with you.

Patient Acknowledgment and Consent

By placing this order, you declare: I have read and understand the above Telehealth Consent and Disclosure. I agree to disclose all relevant and accurate health information to my provider, understand the limitations of remote care, and acknowledge my responsibility to maintain ongoing primary care services. I consent to receiving care from Lifespanning  via telehealth.