Telehealth Consent & Acknowledgment
Prime Harbor Wellness
Telehealth Overview
Telehealth involves the use of secure audio, video, or electronic communication technology to provide real-time healthcare-related consultations, education, and guidance when the patient and provider are in different locations.
At Prime Harbor Wellness, telehealth allows our providers and clinical team to communicate with you remotely to review health information, discuss concerns, and guide next steps. I understand that telehealth relies on technology and that interruptions, technical difficulties, or unauthorized access—though uncommon—may occur. I understand that I may ask questions or request clarification about telehealth services at any time.
Consent to Telehealth Services
I voluntarily request and consent to receive telehealth services from Prime Harbor Wellness, including its physicians, clinicians, wellness professionals, consultants, and support staff (“Practice”), as deemed appropriate.
I understand that:
- Providers may be located in a different physical location than I am
- Telehealth may not include an in-person physical examination
- Services rely on information I provide
- Telehealth does not replace emergency care
- I acknowledge that it is my responsibility to provide complete and accurate
- information regarding my health history, symptoms, medications, and concerns.
- I understand that incomplete or inaccurate information may affect clinical judgment, recommendations, or guidance provided.
- I further understand that healthcare is not an exact science and that no guarantees or assurances can be made regarding outcomes or results.
Limitations of Telehealth
I understand that if Prime Harbor Wellness determines that telehealth is not appropriate to meet my medical or wellness needs, I may be advised to seek in-person medical evaluation or care.
If a telehealth session is interrupted due to technical issues, alternative communication methods may be used, or the session may be rescheduled.
If I experience a medical emergency or urgent condition, I understand that I should contact emergency services by calling 911 or go to the nearest emergency department.
Authorization to Use and Share Information
To facilitate telehealth services, I authorize Prime Harbor Wellness to collect, use, and electronically transmit my personal and health-related information. This may include identifying information, medical history, wellness information, lab or genetic test results, images, audio, video, and other health information (“Personal Information”).
I understand that reasonable safeguards are used to protect the privacy and confidentiality of my information. However, I acknowledge that electronic communication carries inherent risks and that absolute confidentiality cannot be guaranteed.
Right to Withdraw Consent
I understand that I may withdraw my consent to telehealth services at any time by notifying Prime Harbor Wellness verbally or in writing. Withdrawal of consent will not affect care already provided.
Acknowledgment and Agreement
I acknowledge that I have read and understand this Telehealth Consent. I have had the opportunity to ask questions and have received satisfactory answers or have chosen not to ask questions. By proceeding, I voluntarily agree to the terms outlined above.