The following legal consents are provided in English. If you require assistance understanding any section, please contact our office before signing.
Los siguientes consentimientos legales se presentan en inglés. Si necesita ayuda para comprender alguna sección, por favor comuníquese con nuestra oficina antes de firmar.
Billing & Membership Policy – Dr. V Health
⚠️ Important:
An active membership or a Pay-Per-Consult visit is required in addition to the cost of medication.
Membership or consultation fee must be selected and paid at the time of scheduling in order to receive care, prescriptions, or refills.
🔁 Membership Payment Policy
Patients enrolled in a membership are responsible for maintaining an active and valid payment method at all times.
If a membership payment fails, the patient will be notified and must update their payment method promptly to maintain active status.
After three (3) failed payment attempts (“strikes”), the membership will be automatically canceled without further notice.
Once canceled, the patient will lose all membership benefits, including follow-up visits, messaging access, and prescription refills.
Any future care, including medication refills, will require a Pay-Per-Consult or refill visit fee (currently $99).
Re-enrollment in a membership may be required and is subject to provider approval.
🛡️ Additional Policies & Disclosures
1. Telemedicine Consent
By proceeding, you acknowledge that you are requesting care via telemedicine and agree to receive services based on your reported location at the time of the visit. I consent to the use of electronic prescribing to transmit prescriptions to my pharmacy of choice. You may request access to your medical records, request corrections, and file a complaint if you believe your rights have been violated.
2. State Requirement Disclaimer:
Services are only provided to patients physically located in a state where the provider is licensed at the time of the consultation. You confirm that you are physically located in the state you selected at the time of this visit. Services are only provided to patients located in states where the provider is licensed.
3. No Guarantee of Prescription:
Payment does not guarantee that a prescription will be issued. All treatments are based on medical evaluation and provider discretion.
4. Non-Refund Policy:
All consultation and membership fees are non-refundable, including cases where treatment is not prescribed.
5. Patient Responsibility:
Patients are responsible for:
Providing accurate medical history
Completing required forms
Attending scheduled visits
Failure to do so may result in delays or inability to receive treatment.
6. Medication Fulfillment Disclaimer
Medication availability, compounding pharmacies, and shipping timelines are not controlled by Dr. V Health and may vary.
7. Communication Consent:
By submitting this form, you consent to receive communication via SMS, email, or phone regarding your care, appointments, and billing.
(text, email, video) may carry inherent privacy risks despite reasonable safeguards.
8. Dr. V Health does not provide emergency medical services.
If you are experiencing a medical emergency, call 911 or go to the nearest emergency room.
9. Peptide Disclaimer:
Some treatments, including peptide and hormone therapies, may be prescribed off-label and are not FDA-approved for all indications. All treatments are based on provider discretion.
10. HIPAA Authorization and Privacy Acknowledgment
By submitting this form, you authorize Dr. V Health to use and disclose your health information for purposes of treatment, payment, and healthcare operations, in accordance with applicable privacy laws, including HIPAA.
You understand that you may request access to your medical records, request corrections, and request restrictions on certain disclosures.
You acknowledge that a full Notice of Privacy Practices is available upon request.
This authorization remains valid for the duration of the patient-provider relationship unless revoked in writing.