Telemedicine Intake & Consent Form for Oklahoma 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.

OKLAHOMA TELEHEALTH CONSENT
Optimize by JaeNix – JaeNix PLLC | www.jaenixmedspa.com

Telemedicine Overview
Telehealth involves the electronic transmission of medical information for consultation, diagnosis, treatment, follow-up, and patient education. This may include secure video, secure audio, images, records, and electronic prescribing when appropriate.

All systems follow HIPAA and Oklahoma standards for privacy and security.

Expected Benefits
Enhanced access to care
Convenient follow-up and management
Ability to work with specialists remotely

Possible Risks
Technical or connectivity issues
Incomplete data affecting medical decision-making
Rare security/privacy breaches
Possible need for in-person follow-up

Patient Consent
I understand and agree to the following:

Telehealth is voluntary and may be withdrawn at any time.
My provider will decide whether telehealth is clinically safe and appropriate.
My medical information may be disclosed electronically to other clinicians for treatment coordination.
I understand emergency medical needs require calling 911 immediately.
I may need to complete labs or imaging locally.
I understand controlled substances will not be prescribed via telehealth.
I understand no guarantee is made regarding prescriptions.
I may request my medical records at reasonable cost.

Oklahoma-Specific Notices
Pursuant to Oklahoma Statutes (59 O.S. § 478.1, § 539 & OAC 435:10-7-13):

Telemedicine requires the same standard of care as an in-person visit.
Patients have the right to know the identity and credentials of the telehealth provider.
Audio-only telehealth is permitted when appropriate.
Patients have the right to refuse telehealth at any time.

Contact
Optimize by JaeNix – JaeNix PLLC
www.jaenixmedspa.com
214-890-6180
jaenixpllc@icloud.com

Acknowledgment
By checking INFORMED CONSENT FOR TELEHEALTH SERVICES, I confirm I have read and agree to this Oklahoma Telehealth Consent.

Signature

Date