Telemedicine Intake & Consent Form for Iowa 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.

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

Telemedicine Overview
Telehealth involves electronic communication technologies that allow healthcare providers to evaluate, diagnose, treat, and educate patients remotely. Telehealth at Optimize by JaeNix may include medical history review, live audio/video, audio-only telehealth where permitted, medical record sharing, imaging, lab review, and remote prescribing when appropriate.

All systems follow HIPAA-compliant security protocols.

Your primary care provider remains responsible for maintaining your long-term medical record.

Expected Benefits
Improved access to medical evaluation from the patient’s residence or location of choice
More efficient management and follow-up
Access to specialty care without geographic limitation

Possible Risks
Technical failures may cause delays or incomplete evaluation
In rare cases, transmitted data may be insufficient for clinical decision-making
Possible but rare privacy breaches despite HIPAA protections
Incomplete medical record access could contribute to diagnostic or prescribing errors

Patient Consent
By proceeding:

I consent to telehealth services from Optimize by JaeNix (JaeNix PLLC).
I understand telehealth does not replace my primary care provider.
I understand my provider will determine whether telehealth is appropriate for my condition.
I understand that my healthcare information may be transmitted electronically to other treating clinicians as needed.
I understand I may withdraw consent at any time.
I agree to call 911 for emergencies.
I understand I may need to obtain labs or physical evaluations at local facilities.
I understand that no controlled substances will be prescribed via telehealth.
I understand that no guarantee of results is made.
I understand that persons may be present to support telehealth technology and may request they leave at any time.
I may request my medical records at reasonable cost.
I agree to hold Optimize by JaeNix harmless for delays due to technology failure.

Iowa-Specific Statutory Notices
Pursuant to Iowa Code § 147.163 and Iowa Board of Medicine Rules:

I understand that I may refuse telehealth services at any time without affecting future care.
I understand the identity, credentials, and Iowa license status of my telehealth provider will be disclosed to me upon request.
I understand that telehealth in Iowa must meet the same standard of care as in-person visits.

Contact Information
Optimize by JaeNix – JaeNix PLLC
Website: www.jaenixmedspa.com
Phone: 214-890-6180
Email: jaenixpllc@icloud.com

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

Signature

Date