Telemedicine Consent
By accepting this Telemedicine Consent, you consent to receive healthcare services through telemedicine from licensed healthcare providers or clinical partners associated with or coordinated through Vynova Health, including Qualiphy or its affiliated providers.
1. Nature, Benefits, Risks, and Alternatives
Telemedicine uses electronic communications, video, audio, messaging, digital intake forms, and remote technology to allow providers and patients in different locations to communicate and provide healthcare services.
- Potential benefits include convenience, easier access, reduced travel, faster administrative processing, and digital documentation.
- Risks include technology failures, incomplete information, limited physical examination, delays in care, privacy/security risks, and provider refusal to prescribe or proceed remotely.
- Alternatives include in-person care, primary care, specialist consultation, urgent care, emergency care, lifestyle-only programs, and other treatments recommended by a provider.
2. Patient Responsibilities and State Availability
You must provide accurate information, disclose relevant medical history and medications when asked by the provider, be physically located in the state you report during the telemedicine encounter, follow provider instructions, and seek emergency care when needed.
Vynova Health is not currently available for patients located in Alabama, Hawaii, or Mississippi.
3. Privacy, Prescriptions, and Withdrawal
Telemedicine may involve electronic transmission of health information. Prescriptions are not guaranteed, and providers may require additional information, labs, in-person care, or records. You may withdraw consent by contacting the clinical provider or Vynova Health, although that may affect your ability to receive remote services.
Acknowledgment: You acknowledge that you read and understand this Telemedicine Consent, had the opportunity to ask questions, consent to telemedicine services, understand that approval, treatment, and prescriptions are not guaranteed, and understand emergency care should be sought through 911 or emergency services.
Name: ___________________________
Date: ___________________________
Electronic Signature / Checkbox: ___________________________
Consent Version: telemed_v2_2026_05