Informed Consent for Telehealth Services

1. What is Telehealth?

Telehealth refers to the delivery of healthcare services using electronic communications technology, including video conferencing, secure messaging, and digital health platforms. Prime Vitality uses telehealth to provide consultations, ongoing care management, lab result reviews, and prescription services to patients in Utah and other licensed states.

2. Services Provided via Telehealth

Through our telehealth platform, Prime Vitality providers may:

• Conduct initial consultations and health history reviews
• Order and interpret laboratory tests, including hormone panels
• Develop, prescribe, and adjust treatment plans
• Conduct follow-up consultations and monitoring check-ins
• Communicate with you about your care, symptoms, and results
• Refer you to in-person care when clinically appropriate

3. Expected Benefits of Telehealth

Telehealth services offer significant benefits, including:

• Access to licensed clinical care without requiring in-person office visits
• Convenient scheduling and communication from home or work
• Faster access to care compared to traditional clinic models
• Continuity of care through ongoing provider-patient relationships
• Reduced time and cost associated with travel and waiting rooms

4. Risks and Limitations of Telehealth

You acknowledge and understand that telehealth has inherent risks and limitations, including:

Clinical Limitations

• Your provider is unable to physically examine you, which may limit diagnostic capabilities
• Certain conditions may require in-person evaluation, additional testing, or referral to a specialist
• The absence of physical examination may result in errors in assessment or treatment
• Information transmitted electronically may be insufficient in rare cases to make accurate medical decisions

Technology Risks

• Technical failures, including internet outages, video disruptions, or platform errors, may interrupt your consultation
• In the event of a technical failure, your provider will attempt to contact you by phone to continue or reschedule your appointment
• Electronic systems may experience security breaches despite our best safeguards

Privacy Considerations

• You are responsible for ensuring you are in a private location during consultations
• Third parties present in your location during a consultation may overhear medical information
• You should use a private, secure internet connection when accessing telehealth services

5. Your Responsibilities as a Telehealth Patient

To receive safe and effective telehealth care, you agree to:

• Provide complete, accurate, and up-to-date medical information at all times
• Disclose all current medications, supplements, and other healthcare providers
• Inform your provider of any changes in your health status between visits
• Follow your prescribed treatment plan and attend all required follow-up appointments
• Complete required laboratory work at the intervals recommended by your provider
• Contact your provider or seek emergency care if you experience adverse reactions
• Maintain a stable and private environment during your telehealth appointments

6. Informed Consent for Testosterone Replacement Therapy (TRT)

If you are seeking TRT services, you specifically acknowledge the following:

Potential Benefits

• Improved energy, mood, and cognitive function
• Increased libido and sexual function
• Improved body composition, muscle mass, and strength
• Enhanced quality of life and sense of well-being

Potential Risks and Side Effects

• Erythrocytosis: Elevated red blood cell count, which can increase risk of blood clots
• Testicular atrophy: Reduction in testicular size due to suppression of natural testosterone production
• Infertility/reduced sperm production: TRT can significantly reduce or eliminate sperm production
• Estrogen elevation: Conversion of testosterone to estradiol may cause breast tissue sensitivity, water retention, or mood changes
• Acne and skin changes: Increased sebum production may cause or worsen acne
• Sleep apnea: TRT may worsen existing sleep apnea
• Cardiovascular effects: Research on long-term cardiovascular effects is ongoing; we will discuss your individual risk profile
• Prostate effects: TRT is not recommended for men with prostate cancer; PSA levels will be monitored regularly
• Dependence: Once started, stopping TRT may cause your natural testosterone production to remain suppressed temporarily or permanently

Laboratory Monitoring

You understand and agree to complete required blood work at intervals determined by your provider (typically every 3–6 months) to monitor hormone levels, red blood cell counts, PSA, liver function, and lipid panels. Failure to complete required lab work may result in suspension of your prescription.

7. Alternatives to Telehealth

You understand that alternatives to telehealth exist, including in-person consultations with a primary care physician, endocrinologist, or urologist. You have chosen telehealth services voluntarily and understand you may seek in-person care at any time.

8. Right to Withdraw Consent

You have the right to withdraw your consent for telehealth services at any time by notifying us in writing at care@myprimevitality.com. Withdrawal of consent will not affect care already provided. If you withdraw consent, we will work with you to ensure a safe transition, including a medication discontinuation plan if applicable.

9. Emergency Situations

Telehealth services are not appropriate for emergencies. If you experience any of the following, call 911 or go to the nearest emergency room immediately:

• Chest pain, shortness of breath, or signs of heart attack or stroke
• Signs of blood clot (leg swelling, redness, pain; sudden shortness of breath)
• Severe allergic reaction
• Loss of consciousness
• Any other life-threatening situation

10. Confidentiality

All telehealth communications and health information are treated as confidential and protected under HIPAA. Please review our HIPAA Notice of Privacy Practices for full details on how your health information is protected and used.

11. State Licensure

All Prime Vitality providers are licensed to practice medicine in the State of Utah and any other state in which they see patients via telehealth. Services are only provided to patients physically located in states where our providers hold active licensure at the time of the consultation.

12. Contact Us

If you have questions about this consent form before proceeding, please contact us: