Vita Bella Medical Group, P.A. of Florida Patient Informed Consent

Thank you for choosing Vita Bella Medical Group, P.A. of Florida (“Practice”). You are viewing this form because you have elected to engage in telemedicine visits with licensed healthcare practitioners at the Practice. You will be matched with a practitioner who is licensed to practice in your state.

What is Telemedicine?

Telemedicine is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare practitioner. During your telemedicine visit, our healthcare professionals may discuss details of your medical history and personal health information using interactive video, audio, and telecommunications technology. If necessary, a healthcare professional may conduct a virtual physical examination of you, including taking video, audio, and/or photo recordings.

The Practice offers telehealth-based health and wellness services, including weight loss, strength & conditioning, healthy aging, injury & recovery, cognitive health and sexual wellness:

Benefits and Possible Risks of Using Telemedicine

The benefits of telemedicine include having access to medical care anywhere you have access to the internet—including from the comfort of your home. Telemedicine means you don’t risk exposure to illness in busy waiting rooms, and you do not have to wait several days for an in-person appointment. Telemedicine also means you do not have to travel great distances to gain access to specialty care that may not be available in your community.

As with any medical treatment, there are potential risks associated with the use of telemedicine. Practice believes that the chance of any of these risks occurring is very low.

These risks may include, without limitation, the following:

• Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor video and data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your healthcare practitioner should these interruptions occur.
• Security protocols could fail, causing a breach of privacy of personal medical information.
• Because Practice does not have access to your complete medical records, if you do not disclose to your healthcare practitioner a full list of your medical history, including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions, or allergic reactions, or other negative outcomes may occur.

THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE HEALTHCARE PRACTITIONER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTHCARE PRACTITIONER WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR A TELEMEDICINE ENCOUNTER VIA THE SERVICE.

Your Rights and Acknowledgements

• You understand that your healthcare information may be shared with other individuals in accordance with the Practice’s Notice of Privacy Practices and regulations or laws in the state or territory in which you are located.
• Telemedicine may involve electronic communication of your personal medical information to remote healthcare practitioners who may be located outside of your state.
• You have the same privacy rights via telemedicine that you would have during an in-person visit.
• You understand that no results can be guaranteed or assured—you may not achieve the anticipated benefits of the telemedicine services.
• You understand that a variety of alternative methods of medical care may be available to you, and that you may choose one or more of these at any time.
• You understand that all information submitted to Practice will be part of your medical record, and you have the right to review and receive copies of your medical records.
• You attest that you are located in the state checked below and will be present in the state indicated below during all telehealth encounters with Practice.

☐ Arizona           ☐ Florida                            

• Your physician or other healthcare provider has explained to you what telemedicine means, the type of health data that will be collected, and how it will be used in your care;
• Canceling or otherwise ceasing to receive treatment before the end of your current treatment plan may be dangerous. If you stop attending visits and/or complying with your treatment plan at any time, you are responsIble for any adverse outcomes you may experience. THE PRACTICE IS NOT AND CANNOT BE HELD RESPONSIBLE FOR ANY ADVERSE HEALTH OUTCOMES YOU EXPERIENCE AS A RESULT OF YOUR FAILURE TO COMPLY WITH YOUR PROVIDER’S RECOMMENDED TREATMENT PLAN.
• You consent to the use of telemedicine services as part of your care and treatment;
• You have the right to withdraw this consent at any time;
• You are responsible for all applicable costs in receiving the services; and
• Our services are not emergency services. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.
• Drugs and Compounds: Your provider may recommend a scheduled and/or unregulated drug or compound depending on your condition(s). You understand that such drug or compound may cause certain side effects which your healthcare practitioner will explain to you which may vary depending on other medications you take. The Practice will not dispense such drugs or compounds to you. If you purchase any recommended drugs or compounds from one of our online pharmacy partners, your purchase will be subject to that pharmacy’s Terms of Service and Notice of Privacy Practices, not ours.
• HOLD HARMLESS: You represent and warrant that you will provide the Practice with a complete and accurate list of your health conditions, medical history, and current medications. You agree to hold the Practice harmless from responsibility for any adverse side effects which you experience because of your failure to provide us with complete and accurate information. THE PRACTICE IS NOT AND CANNOT BE HELD RESPONSIBLE FOR THE QUALITY OR EFFICACY OF ANY DRUGS OR COMPOUNDS DISPENSED TO YOU BY A THIRD-PARTY PHARMACY.

This Patient Informed Consent is valid during your entire treatment with Practice. If you would like to withdraw consent, you must do so prior to receiving any further treatment by emailing us at support@vitabella.com. Your withdrawal of consent will not affect your right to receive future care or treatment.