$25 OFF ORDER FOR NEXT 500 PATIENTS! Use Code: PRIMELIFE
$25 OFF ORDER FOR NEXT 500 PATIENTS! Use Code: PRIMELIFE
Last Updated: April 2025
OUR HEALTHCARE PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY, YOU SHOULD DIAL 911 OR GO TO THE NEAREST EMERGENCY ROOM.
Telehealth is a mode of delivering health care services via communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.
You are reviewing and acknowledging this Telehealth Consent Form because you are seeking healthcare services (the “Services”) from Prime LifeMD and its affiliated entities (collectively, the “Practice“) utilizing telehealth technologies facilitated through the Prime LifeMD website, mobile app, or partner platform (collectively, the “Platform”). This Telehealth Consent Form supplements but does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of Prime LifeMD or o...
[Full treatment-specific consent section as provided, including statements of consent to telehealth, risks, limitations, provider qualifications, medical record access, prescriptions, HIPAA, emergency limitations, and more.]
The following consent applies to patients who receive a prescription from a Provider for compounded medications.
I understand that the FDA does not approve nor review compounded products for safety, effectiveness, or quality. I understand that compounding pharmacies must adhere to strict quality control standards and are subject to state and federal regulations.
I acknowledge that I may be offered a telehealth consultation related to my mental or behavioral health as part of the Services. I understand this may differ from in-person therapy due to the nature of technology. I understand that confidentiality is protected, exceptions apply (harm, abuse, legal situations), and teletherapy is not intended for emergency care. I agree to provide emergency contact information at the start of each session.
HIV is the virus that causes AIDS. HIV can be transmitted through unprotected sex, blood contact, or mother-to-child transmission. The test determines whether you have been exposed to HIV. A positive result means infection but not necessarily AIDS. A negative result does not guarantee absence of infection if exposure was recent. Taking an HIV test is voluntary. Confidentiality laws apply but results may be reported to health authorities as required by law.
Genetic testing may be offered as part of the Services. Risks, benefits, and implications will be explained. I may request professional genetic counseling before proceeding. I will be informed of the testing method and have the right to make an informed decision.
By clicking “I accept”, I confirm that the above information is true. I authorize Prime LifeMD to bill my insurance and receive direct payments. I understand I am financially responsible for unpaid balances. I allow my health information to be disclosed for payment processing.
I authorize Prime LifeMD to contact me by phone, SMS, or email for appointment reminders and general health information. I understand that these communications may not be secure. This consent remains valid until I request a change in writing.
This section includes legal disclosures required for specific states including Alaska, California, Connecticut, Kansas, New Hampshire, New Jersey, Ohio, South Carolina, Texas, Vermont, Wyoming, and more. These include rights to access telehealth records, billing protections, and formal complaint procedures. Visit your state’s medical board for complaint filing details.
