Telemedicine Intake & Consent Form for Florida 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.

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

Telemedicine Overview
Telehealth involves the remote provision of healthcare services using electronic communication technologies. This may include video visits, audio-only visits, medical record review, electronic prescribing where appropriate, and collaborative consults.

Optimize by JaeNix uses HIPAA-secure platforms.

Expected Benefits
Convenient access to licensed Florida telehealth providers
Faster diagnosis, treatment, and follow-up
Access to specialty care

Possible Risks
Technology failures
Data transmission errors
Rare privacy/security breaches
Possible need for in-person evaluation

Patient Consent
I agree and understand:

I am receiving telehealth services from a Florida-registered telehealth provider.
Telehealth does not replace the need for a primary care physician.
My provider will use clinical judgment to determine appropriateness of telehealth.
I may withdraw consent at any time.
I understand emergency conditions require calling 911.
I may need labs or physical tests performed locally.
No controlled substances will be prescribed.
There is no guarantee any prescription will be issued.
I may request medical records at reasonable cost.
I understand telehealth records may be shared with other clinicians as appropriate.

Florida-Specific Notices
In accordance with Florida Statute § 456.47 (Florida Telehealth Act):

I understand my provider must be registered or licensed to treat Florida patients.
I understand telehealth must meet the same standard of care as in-person services.
I understand that telehealth may involve out-of-state providers registered with Florida.
I understand I may 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 understand and agree to the Florida Telehealth Consent.

Signature

Date