Telehealth Informed Consent

Effective Date: January 1, 2026
Last Updated: August 1, 2026

Incipio Health LLC d/b/a ProMedicaMD
3300 Hamilton Mill Rd, Ste 102, PMB 3011
Buford, GA 30519

1. PURPOSE OF THIS CONSENT

This Telehealth Informed Consent explains how ProMedicaMD may provide healthcare services using telehealth technologies and the potential benefits, limitations, risks, and alternatives associated with receiving healthcare through telehealth.

By signing or electronically accepting this Consent, you acknowledge that you have been informed about telehealth and voluntarily consent to receive telehealth services from ProMedicaMD when your healthcare professional determines that telehealth is appropriate.

This Consent applies to telehealth services provided by ProMedicaMD healthcare professionals, subject to applicable law and any additional consent requirements that may apply to a particular service or jurisdiction.

2. WHAT IS TELEHEALTH?

Telehealth is the delivery of healthcare services through electronic communication technologies when the patient and healthcare professional are in different locations.

Telehealth may include:

• Live video appointments;
• Telephone appointments;
• Secure electronic messaging;
• Patient portal communications;
• Electronic transmission of medical information;
• Remote monitoring;
• Review of photographs or other patient-submitted information;
• Electronic prescriptions; and
• Other legally permitted remote healthcare technologies.

3. SERVICES THAT MAY BE PROVIDED

Depending upon your medical needs, eligibility, physical location, provider licensure, and applicable law, telehealth services may include:

• General medical care;
• Urgent care;
• Weight-management services;
• Hormonal health services;
• Restorative care;
• Preventive healthcare;
• Medication management;
• Laboratory review;
• Follow-up care; and
• Other medical services determined appropriate by your healthcare professional.

Not every service is available through telehealth or in every state.

4. HOW THE TELEHEALTH VISIT WORKS

A telehealth encounter may generally involve:

• Confirming your identity;
• Confirming your physical location;
• Reviewing your medical history;
• Discussing your symptoms or health concerns;
• Reviewing medications and allergies;
• Reviewing relevant laboratory or diagnostic information;
• Conducting a remote clinical assessment;
• Developing an appropriate treatment plan;
• Ordering laboratory testing or other services when appropriate;
• Prescribing medication when clinically appropriate and legally permitted; and
• Arranging follow-up or referral when appropriate.

Your healthcare professional may ask you to provide additional information, measurements, photographs, laboratory results, or other information when clinically appropriate.

5. PATIENT LOCATION

I understand that I must accurately tell ProMedicaMD where I am physically located at the time of a telehealth encounter.

I understand that healthcare professionals may be required to comply with the laws and professional requirements of the state in which I am physically located.

ProMedicaMD currently provides telehealth services to eligible patients located in:

• Georgia;
• Florida;
• Alabama; and
• Louisiana.

I agree not to misrepresent my location in order to receive healthcare services.

If I travel outside these states, I understand that telehealth services may not be available to me.

6. BENEFITS OF TELEHEALTH

Potential benefits of telehealth include:

• Greater convenience;
• Reduced travel;
• Improved access to healthcare;
• Ability to receive certain services from home or another location;
• More flexible access to healthcare professionals;
• Ability to communicate electronically with my healthcare team; and
• Potentially faster access to certain healthcare services.

I understand that the benefits of telehealth may vary depending upon my medical condition and circumstances.

7. LIMITATIONS AND RISKS OF TELEHEALTH

I understand that telehealth has limitations and risks.

These may include:

• The healthcare professional cannot perform every component of an in-person physical examination;
• Certain medical conditions may be difficult or impossible to evaluate remotely;
• The healthcare professional may not have access to all relevant clinical information;
• Internet or cellular service may fail;
• Video or audio may stop working;
• The connection may be interrupted;
• Information may be delayed or lost;
• Technology may malfunction;
• Electronic communications may involve privacy or security risks;
• My condition may require an in-person examination;
• I may require laboratory testing, imaging, or other diagnostic services; and
• I may need emergency or urgent in-person medical care.

I understand that my healthcare professional may stop or change a telehealth encounter if telehealth is not clinically appropriate.

8. PRIVACY

I understand that ProMedicaMD will use reasonable safeguards designed to protect my health information.

I understand that telehealth uses electronic communications and that no electronic system can be guaranteed to be completely secure.

I agree to take reasonable steps to protect my own privacy, including:

• Participating from a private location when possible;
• Using headphones when appropriate;
• Protecting my device and account passwords;
• Avoiding public Wi-Fi when reasonably possible;
• Preventing unauthorized individuals from viewing or hearing the appointment; and
• Not recording the encounter without appropriate permission.

ProMedicaMD’s privacy practices are described in its Notice of Privacy Practices.

9. OTHER PEOPLE PRESENT DURING THE VISIT

I understand that I should inform my healthcare professional if another person is physically present with me during a telehealth appointment.

I understand that my healthcare professional may also inform me if another person is present with the healthcare professional during the appointment.

I may ask who is present during my telehealth appointment.

Where appropriate, consent will be obtained before additional individuals participate in the encounter.

10. RECORDING OF TELEHEALTH VISITS

ProMedicaMD does not automatically guarantee that telehealth encounters will be recorded.

If ProMedicaMD intends to record an encounter for a purpose requiring consent, I understand that I will be informed and appropriate consent will be obtained.

I agree not to record, photograph, screenshot, or otherwise capture a telehealth encounter without first obtaining appropriate permission and complying with applicable law.

11. EMERGENCY CARE

I understand that ProMedicaMD telehealth is not an emergency medical service.

I will not rely on a telehealth appointment, patient portal message, email, text message, or other ProMedicaMD communication for emergency medical care.

If I believe I am experiencing an emergency, I will immediately:

Call 911; or

Go to the nearest emergency department.

Examples of potentially serious symptoms include:

• Chest pain;
• Severe difficulty breathing;
• Severe bleeding;
• Loss of consciousness;
• Stroke symptoms;
• Seizure;
• Severe allergic reaction;
• Serious injury;
• Severe or rapidly worsening symptoms;
• Suicidal or homicidal thoughts; or
• Any condition that may be life-threatening.

12. IN-PERSON CARE

I understand that telehealth may not be appropriate for every medical condition.

My healthcare professional may recommend:

• An in-person examination;
• Laboratory testing;
• Imaging;
• Emergency department evaluation;
• Urgent care;
• Specialist consultation;
• Hospital evaluation; or
• Other in-person healthcare.

I understand that I should follow such recommendations.

13. MEDICAL DECISION-MAKING

I understand that my healthcare professional will exercise independent clinical judgment.

I understand that:

• A prescription is not guaranteed;
• A requested medication may not be prescribed;
• A requested treatment may not be appropriate;
• Additional laboratory testing may be required;
• Follow-up appointments may be required;
• An in-person examination may be required; and
• Treatment may be changed or discontinued when clinically appropriate.

14. WEIGHT MANAGEMENT

If I receive weight-management services, I understand that:

• Treatment is individualized;
• Eligibility for treatment or medication is determined by a healthcare professional;
• Certain medications may require laboratory monitoring;
• Medications may have risks, side effects, contraindications, and interactions;
• Weight-loss results vary among individuals; and
• No particular amount or rate of weight loss is guaranteed.

I agree to provide complete and accurate information relevant to my weight-management care.

15. HORMONAL HEALTH

If I receive hormonal health services, I understand that:

• Hormonal treatment is individualized;
• Laboratory testing may be required;
• Treatment may require ongoing monitoring;
• Hormonal medications may have risks and side effects;
• Treatment may be inappropriate for certain patients; and
• No particular treatment result or hormone level is guaranteed.

I agree to provide accurate information concerning my health, medications, medical history, and other clinically relevant information.

16. URGENT CARE

I understand that ProMedicaMD may evaluate certain non-life-threatening urgent medical concerns through telehealth.

I understand that telehealth may not be appropriate for my particular condition.

If my healthcare professional determines that I require emergency or in-person care, I agree to follow those recommendations.

I understand that delays may occur if I use telehealth for a condition that requires in-person evaluation.

17. MEDICATIONS AND PRESCRIPTIONS

I understand that my healthcare professional may prescribe medication only when clinically appropriate and legally permitted.

I understand that:

• A prescription is not guaranteed;
• Medication availability may vary;
• Pharmacies may have their own requirements;
• Some medications are subject to additional legal restrictions;
• Laboratory testing may be required;
• Follow-up may be required; and
• I am responsible for taking medications according to my healthcare professional’s instructions.

I agree to inform my healthcare professional of all medications, supplements, allergies, and relevant medical conditions.

18. LABORATORY TESTING

I understand that my healthcare professional may recommend laboratory testing.

I understand that laboratory testing may be necessary to:

• Evaluate my condition;
• Determine whether treatment is appropriate;
• Monitor medication;
• Assess treatment response; or
• Identify potential medical risks.

I agree to complete recommended laboratory testing and follow up regarding abnormal results.

19. PATIENT RESPONSIBILITIES

I agree to:

• Provide accurate and complete medical information;
• Accurately report my physical location;
• Participate from an appropriate location when possible;
• Follow medical instructions;
• Complete recommended testing;
• Attend follow-up appointments;
• Report significant changes in my health;
• Report medication side effects or concerning symptoms;
• Protect my account credentials;
• Seek emergency care when appropriate; and
• Notify my healthcare professional if I believe telehealth is not adequate for my needs.

20. VOLUNTARY CONSENT

I understand that participation in telehealth is voluntary.

I have had an opportunity to ask questions about telehealth.

I understand the potential benefits, limitations, risks, and alternatives to telehealth.

I understand that I may discuss alternatives to telehealth with my healthcare professional.

I understand that refusing telehealth does not necessarily prevent me from seeking healthcare elsewhere.

21. ELECTRONIC CONSENT

I understand that my consent may be documented electronically.

By checking an electronic consent box, signing electronically, or otherwise affirmatively indicating consent through the ProMedicaMD platform, I intend to provide the same consent as if I had signed this document by hand, to the extent permitted by applicable law.

22. STATE-SPECIFIC REQUIREMENTS

I understand that telehealth requirements may vary depending upon the state in which I am physically located.

I understand that ProMedicaMD may provide additional state-specific disclosures or consent forms when required.

Nothing in this Consent is intended to override a mandatory requirement of applicable federal or state law.

23. WITHDRAWAL OF CONSENT

I may withdraw my consent to receive telehealth services by notifying ProMedicaMD.

Withdrawal of telehealth consent does not necessarily require ProMedicaMD to delete medical records or information that it is legally required to maintain.

Withdrawal of consent also does not necessarily affect healthcare services that have already been provided.

If I withdraw telehealth consent, I understand that ProMedicaMD may be unable to provide certain services remotely.

24. ACKNOWLEDGMENT

By signing or electronically accepting this Telehealth Informed Consent, I acknowledge that:

☐ I understand what telehealth is.

☐ I understand the potential benefits and limitations of telehealth.

☐ I understand the potential privacy and technology risks.

☐ I understand that telehealth is not an emergency service.

☐ I understand that I must accurately report my physical location.

☐ I understand that my healthcare professional may require in-person care.

☐ I understand that treatment and prescriptions are not guaranteed.

☐ I understand that I may ask questions regarding telehealth.

☐ I voluntarily consent to receive appropriate healthcare services through telehealth.