Telemedicine Intake & Consent Form for Colorado 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.

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

Telemedicine Overview
Telehealth uses secure electronic communication to deliver clinical services remotely. This may include video visits, audio consultations, electronic prescribing, remote monitoring, or healthcare data exchange.

All systems follow HIPAA-compliant security standards.

Expected Benefits
Increased access to care
Timely treatment
Access to specialists not available locally

Possible Risks
Technical difficulties causing delays
Data quality issues requiring in-person evaluation
Rare privacy or security failures
Incomplete medical data potentially affecting clinical decisions

Patient Consent
I understand and agree:

Telehealth is voluntary and may be discontinued at any time.
My provider will determine whether telehealth is appropriate.
My medical information may be shared electronically with other treating providers.
I must seek emergency care (911) for urgent medical needs.
Not all conditions can be treated via telehealth.
No controlled substances will be prescribed via telehealth.
There is no guarantee that any prescription will be issued.
I may request medical records at reasonable cost.
I agree to hold Optimize by JaeNix harmless for technological delays beyond their control.

Colorado-Specific Notices
Pursuant to Colorado Revised Statutes (C.R.S. § 10-16-123, § 12-240-107):

I understand that telemedicine in Colorado must meet the same standard of care as in-person care.
I understand that I have the right to information about all parties present during a telehealth visit.
I understand I may refuse telehealth at any time without affecting future treatment.
I understand audio-only telehealth is permitted when medically appropriate.

Contact Information
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 Colorado Telehealth Consent.

Signature

Date