Telehealth Informed Consent — Serene Telehealth with Dr. Robin Arora
Telehealth informed consent for Serene Medical Spa LLC. Patients must be 18 or older. Please complete all required fields and acknowledgements before signing.
Patient Information
Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
State where you will be physically located during your telehealth visits
*
Please Select
Ohio
West Virginia
Kentucky
Florida
Other (we cannot see you by telehealth — please call us).
Eligibility Requirement
Telehealth means receiving medical care by live video, phone or secure messaging instead of in person. Serene Telehealth visits are conducted by Robin Arora, MD (board certified, American Board of Internal Medicine) through Spruce Health, a HIPAA-compliant platform. Dr. Arora is licensed in Ohio, West Virginia, Kentucky and Florida; you must be physically located in one of these states at the time of each visit. Patients must be 18 or older.
Benefits and limitations
Telehealth can make care more convenient and timely. It also has limits: Dr. Arora cannot perform a hands-on physical exam, technology can fail or be interrupted, and in rare cases information could be lost or accessed without authorization despite safeguards. Dr. Arora may decide that telehealth is not appropriate for your condition and refer you for in-person care, labs or imaging. Telehealth is not for emergencies — if you have a medical emergency, call 911.
Prescriptions
A prescription is considered only after Dr. Arora has completed a live evaluation, reviewed your history and any labs, and established a physician–patient relationship. Booking a visit or paying the program fee does not guarantee a prescription. Medications such as GLP-1 weight-management drugs and hormone therapies have known risks and side effects that Dr. Arora will review with you. Prescriptions are sent electronically to the pharmacy of your choice or, if you prefer, to our partner compounding pharmacy, Boudreaux's New Drug Store (Lake Charles, LA), which is licensed to ship to Ohio, West Virginia, Kentucky and Florida. Medication is paid for separately, directly to the pharmacy. Serene does not sell or ship medication.
Fees
The Serene Telehealth program fee is $149 per month, which covers your video visits, follow-ups and secure messaging with Dr. Arora. It does not include medication, labs or in-person services. We do not bill insurance for telehealth. Our refund and cancellation terms are at serenemedspas.com/terms-of-service.
Privacy
Your health information is protected under HIPAA and our Notice of Privacy Practices (serenemedspas.com/privacy-practices). Visits are not recorded unless you are told and agree in advance. Please choose a private location for your visits.
Your rights
You may withdraw this consent and stop telehealth care at any time without affecting your right to future care. You may choose in-person care at our Hudson, OH or Barboursville, WV offices instead. You may ask questions about telehealth at any time.
Acknowledgements
Acknowledgements
*
I have read and understand this consent, and my questions have been answered.
I confirm I will be physically located in Ohio, West Virginia, Kentucky or Florida during each telehealth visit and will tell Dr. Arora if my location changes.
I understand a prescription is not guaranteed and that medication is prescribed only when medically appropriate.
I understand telehealth is not for emergencies and I will call 911 in an emergency.
I agree to the $149/month program fee and understand medication and labs are separate.
Signature
Electronic Signature
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sign and submit consent
Sign and submit consent
Should be Empty: