Telemedicine Intake & Consent Form for Texas Residents

Name

First NameMiddle NameLast NameSuffix

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.

Preferred Pharmacy Name and Location (City/State):

Please select the reason for your visit from the options below or provide a brief description of your specific needs:

Weight Loss Management – Discuss personalized weight loss options and medication plans.Hormone Replacement Therapy (HRT/BHRT) – Review symptoms of hormonal imbalance and explore treatment options.General Wellness Consultation – Explore IV therapy, vitamin injections, and overall wellness optimization.Telehealth Urgent Care Visit – Address acute concerns such as minor illnesses, infections, or general health inquiries.

If other, please list here.

Introduction

Telemedicine involves the use of electronic communications to provide healthcare services remotely. This includes consultation, diagnosis, treatment, education, and care management. The use of telemedicine allows you to receive medical services without needing to visit a clinic in person.

Scope of Telemedicine Services

By signing this consent form, you understand and agree that:
Telemedicine may involve video calls, audio calls, secure messaging, or other electronic communication. The healthcare provider will assess, diagnose, and provide treatment recommendations based on the information provided.

Telemedicine does not replace in-person care when it is required.
You may need to seek emergency care or in-person consultation when deemed necessary by the provider.

The provider cannot prescribe controlled substances via telemedicine under Texas law.

Telemedicine visits may be conducted synchronously (live video or audio consultations) or asynchronously (store-and-forward technology, where the patient submits health information, photos, or questions, and the provider reviews and responds later).

Benefits of Telemedicine

Convenience of remote consultations
Reduced travel time and costs
Access to medical expertise, even in rural or underserved areas
Flexibility with asynchronous visits for minor conditions, allowing the provider to review information and respond at a later time

Limitations & Risks of Telemedicine

Technical failures, such as poor internet connection, may affect communication.
The provider may not be able to conduct a full physical exam, which could impact diagnosis and treatment.
In rare cases, security protocols could fail, leading to unauthorized access to personal health information.
Asynchronous visits may not be suitable for all conditions, and a follow-up video or in-person visit may be required.

Patient Rights & Responsibilities

You have the right to withdraw consent at any time.
You may request in-person services at any time if needed.
You must provide accurate and complete health information during the consultation.
You must inform the provider of any changes in your condition.
You understand that telemedicine is not for emergency care. If you experience a medical emergency, you should call 911 or visit the nearest emergency room.

Confidentiality & Privacy

Telemedicine services follow HIPAA regulations to protect your health information.
Electronic communication will be securely stored and maintained in compliance with Texas law.

You authorize the healthcare provider to share information with other healthcare professionals when necessary for your treatment.

Financial Responsibility

We do not bill insurance for telemedicine services.
You agree to pay the fees associated with your telemedicine visit as disclosed before the consultation.

Acknowledgment & Consent

By signing below, you acknowledge that you have read and understand this Telemedicine Consent Form. You agree to participate in telemedicine services under the terms outlined above.

Signature

Date