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[LEGAL ENTITY NAME, PLLC], doing business as Xenith Health, [STREET ADDRESS], Amarillo, TX [ZIP], provides telemedicine medical services to patients located in Texas through physicians licensed by the Texas Medical Board. Texas Occupations Code §111.002 requires us to obtain your informed consent before providing telemedicine services. By checking the consent box on our consult form and again during intake, you confirm that you have read and agree to the following.
1. What telemedicine is
Telemedicine means your physician evaluates and treats you using interactive audio and video, secure messaging, and electronic health records, rather than in person. Your physician may also review photographs, lab results, and questionnaires you provide.
2. Expected benefits
- Access to physician care from home.
- Faster follow-up for dosing changes and side-effect questions.
- A continuous record shared with your care team and your pharmacy.
3. Possible risks and limitations
- Your physician cannot perform a hands-on exam. Some conditions cannot be diagnosed or treated by telemedicine, and your physician may require an in-person visit, laboratory testing, or a referral.
- Delays or interruptions can occur because of technology failures. If a visit is interrupted, we will call you at the number on file.
- In rare cases, security protocols could fail and your information could be accessed by unauthorized persons. We use encrypted platforms with business associate agreements to reduce this risk.
- Prescriptions are issued only when your physician determines treatment is appropriate. Requesting or paying for a consult does not guarantee a prescription.
4. Your physician and your location
Before care begins we will tell you the name and credentials of the physician treating you. Our physicians are listed on the About page. You agree to tell us where you are physically located at the start of each visit and to join visits only from Texas.
5. Medications
Prescriptions are filled by an independent licensed pharmacy, King Compounding Pharmacy. Compounded medications are not FDA-approved and are not the same as FDA-approved brand-name products. Your physician will explain the medication prescribed, how to take it, common side effects, and when to seek care.
6. Emergencies
Telemedicine is not for emergencies. If you have chest pain, difficulty breathing, severe allergic reaction, thoughts of harming yourself, or any other emergency, call 911 or go to the nearest emergency room.
7. Your medical record and privacy
Your telemedicine visits become part of your medical record, which is protected under HIPAA and Texas law. Your information may be disclosed electronically to your pharmacy, laboratory, and others involved in your care as described in our Notice of Privacy Practices. You confirm that you have received that notice. Visits are not recorded without your separate permission.
8. Your rights
- You may withhold or withdraw this consent at any time without affecting your right to future care.
- You may ask questions about telemedicine at any time and request an in-person appointment at our Amarillo office where appropriate.
- You may request a copy of your record and a copy of this consent.
- You may file a complaint with the Texas Medical Board. See the Notice Concerning Complaints.
9. Fees
Telemedicine visits and memberships are cash pay. Fees, billing frequency, and cancellation terms are disclosed before you are charged and in the Refund & Cancellation Policy.
Consent statement
I have read this consent and understand it. I have had the chance to ask questions. I understand the benefits, risks, and limits of telemedicine described above. I agree to receive telemedicine medical services from Xenith Health physicians, and I understand that I may withdraw this consent at any time.
Contact
[LEGAL ENTITY NAME, PLLC] d/b/a Xenith Health · [PHONE] · hello@xenithhealth.com