Optimize by JaeNix – Telemedicine Consent Form
JaeNix PLLC | www.jaenixmedspa.com
Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share patient medical information for the purpose of improving patient care. Telehealth at Optimize by JaeNix (JaeNix PLLC) may include remote evaluation, follow-up visits, prescribing when clinically appropriate, lab review, health coaching, and non-clinical services such as scheduling and patient education.
Providers may include nurse practitioners, collaborating physicians, or other licensed healthcare professionals. Telehealth communications may be used for diagnosis, treatment, follow-up, and/or education and may involve:
Electronic medical records
Medical images or documents
Live two-way audio and/or video
Interactive audio-only services where permitted
Remote monitoring or device-generated data
Secure electronic systems will be used that follow network and software security protocols to protect the confidentiality and integrity of patient information.
Primary medical responsibility should remain with your local primary care provider (if you have one), including maintaining your complete medical record.
Expected Benefits
Improved access to medical care by allowing you to remain at home or another convenient location.
More efficient evaluation, management, and follow-up.
Access to providers who may not be located near you.
Faster prescription management and lab review when clinically appropriate.
Possible Risks
Delays in medical evaluation due to equipment, internet, or technological failures.
In rare cases, inaccurate or incomplete information may necessitate an in-person visit.
Security protocols could potentially fail, resulting in a breach of privacy.
Limited access to your full medical history may lead to medication or diagnostic errors.
Patient Consent
By proceeding, you acknowledge, understand, and consent to the following:
You consent to receiving healthcare services via telemedicine from Optimize by JaeNix (JaeNix PLLC).
Telemedicine services do not replace your relationship with a primary care provider.
Your provider will determine whether telehealth is clinically appropriate for your needs.
You understand that Optimize by JaeNix follows federal and state privacy laws and takes steps to ensure that your protected health information is not seen by unauthorized individuals.
Telehealth may involve transmission of your medical information to other healthcare professionals for consultative, treatment, laboratory, or pharmacy purposes.
You agree to hold harmless Optimize by JaeNix (JaeNix PLLC) for delays or data loss caused by technical failures beyond our control.
You may withhold or withdraw consent for telehealth at any time without affecting your right to future care.
If experiencing a medical emergency, you agree to call 911 immediately.
Optimize by JaeNix cannot connect you directly to emergency services.
You understand that some parts of the exam (e.g., vital signs, labs, measurements) may be performed by individuals at your location or at a lab/testing facility.
Audio and/or video images may be captured and stored for documentation purposes. These may be viewed by licensed staff for evaluation, quality assurance, or training, consistent with HIPAA.
No guarantee of results is made or implied regarding the outcome of telehealth services.
You understand persons other than your provider (such as technical support staff) may be present to operate telehealth technology, and you may request:
Omission of sensitive information
Removal of non-medical personnel
Termination of the consultation at any time
Controlled Substances:
You understand that you may not be prescribed any DEA-controlled substances via telehealth unless permitted by federal/state law and clinical judgment. There is no guarantee that a prescription of any kind will be provided.
You may request a copy of your medical records. Reasonable fees for preparation and delivery may apply.
In the event of any malfunction or dissatisfaction with the telehealth platform, your sole remedy is to discontinue use of telehealth services.
Texas-Specific Notices (as required by law)
Texas Medical Records Sharing:
You understand that your medical records may be sent to your primary care physician. (Tex. Occ. Code 111.005)
Texas Medical Board Complaint Notice:
Complaints regarding providers licensed by the Texas Medical Board may be submitted to:
Texas Medical Board – Investigations
333 Guadalupe, Tower 3, Suite 610
P.O. Box 2018, MC-263
Austin, Texas 78768-2018
Phone: 1-800-201-9353
Website: www.tmb.state.tx.us
Aviso en Español: (unchanged to satisfy requirements)
Las quejas sobre médicos y otros profesionales acreditados pueden presentarse en la dirección arriba mencionada. Asistencia disponible al 1-800-201-9353.
Contact Information
For follow-up care, adverse reactions, or technical issues, you may contact:
Optimize by JaeNix – JaeNix PLLC
Website: www.jaenixmedspa.com
Email: jaenixpllc@icloud.com (or preferred clinic email)
Phone: 214-890-6180
If you experience a medical emergency, call 911 immediately.
Patient Acknowledgment & Consent
By checking the box labeled “INFORMED CONSENT FOR TELEHEALTH SERVICES,” I confirm the following:
I have read, understand, and voluntarily agree to the terms above.
I consent to participate in telehealth services provided by Optimize by JaeNix (JaeNix PLLC).
I understand that checking this box serves as my electronic signature.