This Telehealth Informed Consent (“Consent”) describes the nature of telehealth services offered through EdgeRx and the Wizlo provider network, and the risks, benefits, and alternatives associated with receiving care in this way.
Please read this Consent carefully before beginning any consultation.
By proceeding with an intake or consultation, you acknowledge that you have read, understood, and agree to this Consent.
Telehealth, also called telemedicine, is the use of secure electronic communication, including messaging, questionnaires, photographs, and, where applicable, audio or video visits, to deliver health care services when the provider and patient are not in the same physical location.
Through EdgeRx, telehealth is used to complete an intake, communicate with a licensed provider, and, if the provider determines it is clinically appropriate, receive a prescription.
Providers who evaluate and treat patients through EdgeRx are independent, licensed, board-certified professionals employed by or contracted with [PROVIDER GROUP LEGAL NAME], made available through the Wizlo provider network.
A provider-patient relationship is established only once a licensed provider reviews your intake and affirmatively agrees to provide care.
The provider, not EdgeRx, is responsible for all clinical decisions, including:
Consultations and communications take place through the Wizlo platform, which is designed to be HIPAA-compliant and uses administrative, technical, and physical safeguards intended to protect the confidentiality of your health information.
These safeguards include encrypted transmission of messages, images, and any video communications.
As with any technology, telehealth tools may be subject to technical interruptions, as described under the Risks and Limitations section below.
Telehealth can offer benefits such as:
These benefits will vary depending on your individual circumstances, and we do not guarantee that you will experience any particular benefit.
You understand and acknowledge the following risks and limitations associated with telehealth.
Video, audio, or messaging connections may be delayed, interrupted, or of poor quality due to technical issues outside our control.
These issues could delay evaluation, communication, or treatment.
Because your provider is not physically present, they cannot perform an in-person physical examination.
Diagnosis and treatment recommendations are based on the information, medical history, photographs, images, or lab results provided by you and other permitted sources.
This may result in less complete information than an in-person visit would provide.
In some cases, a provider may determine that an in-person evaluation, additional testing, or referral to another provider is necessary before treatment can proceed.
Telehealth relies on you providing complete and accurate information.
Provider review is not always immediate, so there may be a delay between when you submit an intake and when you receive a response, recommendation, or prescription.
Your provider may determine, based on your intake, medical history, lab results, or subsequent communications, that:
Submitting an intake or making a purchase does not guarantee that any specific product will be prescribed.
The Wizlo platform is designed with safeguards intended to protect your information.
However, as with any electronic communication, there is an inherent risk that health information transmitted electronically could be intercepted, accessed, or disclosed without authorization despite security measures.
Alternatives to receiving care through EdgeRx’s telehealth Services include:
You are not required to use EdgeRx’s Services and may choose an in-person alternative at any time.
Completing an intake, scheduling a consultation, or making a payment does not guarantee that:
Your provider retains full discretion to decline to treat you, recommend an alternative treatment plan, or discontinue treatment at any time based on their independent clinical judgment.
Telehealth through EdgeRx is not appropriate for medical emergencies.
If you are experiencing a medical emergency, including but not limited to:
Call 911 or go to the nearest emergency room immediately.
Do not attempt to reach a provider through the EdgeRx platform for an emergency, as response is not immediate and the platform is not monitored on a 24/7 emergency basis.
If your provider recommends a compounded medication, which may include certain peptides, semaglutide compounds, or tirzepatide compounds, you specifically acknowledge and consent to the following:
[PHARMACY PARTNER(S)] or other licensed pharmacy partners.If you are prescribed hormone-related therapy, including testosterone cypionate or human chorionic gonadotropin, you acknowledge that:
If you are prescribed a peptide, such as BPC-157, TB-500, CJC-1295, Sermorelin, Ipamorelin, MOTS-C, Tesamorelin, AOD-9604, or 5-Amino-1MQ, you acknowledge that:
Information exchanged during your telehealth consultation is protected health information and is subject to the same confidentiality protections as information shared during an in-person visit.
This information is handled in accordance with HIPAA and our Notice of Privacy Practices, available at: Notice of Privacy Practices.
Please review that notice for a full description of how your health information may be used and disclosed.
Consultations, messages, and video visits, if applicable, are not recorded for purposes other than the operation and clinical documentation of the Services.
They will not be recorded for any other purpose without separate disclosure to you and, where required by law, your consent.
You may withdraw your consent to telehealth services at any time by:
team@edgerx.comWithdrawing consent may affect your ability to continue receiving care through EdgeRx and may affect pending prescriptions or active treatment plans.
Withdrawal of consent does not affect the validity of consultations or treatment already provided.
[STATE-SPECIFIC ADDENDA]
Certain states have specific informed-consent requirements for telehealth, including required disclosures, specific consent formats, or verbal consent requirements.
Counsel should insert any required state-specific consent language for the states in which EdgeRx operates.
By checking the box or otherwise indicating your agreement electronically, you acknowledge that:
Patient name: ______________________
Date of birth: ______________________
Electronic signature: ______________________
Date: [EFFECTIVE DATE]
EdgeRxLLC
Business address: 30 N Gould St #4501 Sheridan, WY 82801
Privacy inquiries: team@edgerx.com
General support: team@edgerx.com
Medical Director: [MEDICAL DIRECTOR NAME, MD]
Last updated: [EFFECTIVE DATE]
