Clinical consents.

[DRAFT TEXT] I understand that The Integra Clinic provides care exclusively through telehealth — audio and video visits conducted remotely rather than in person. I understand the potential benefits of telehealth (convenience, access to care from home) as well as its limitations (no physical examination, potential technology interruptions, and that some conditions may require in-person evaluation, imaging, or emergency care that cannot be provided remotely).

I understand that if my provider determines my concern is not appropriate for telehealth, I will be referred to in-person or emergency care as needed. I understand this is not an emergency service, and that for any medical emergency I should call 911 or go to the nearest emergency room.

By checking the box below, I confirm I have read and understood this consent and agree to receive care from The Integra Clinic by telehealth.

[DRAFT TEXT] I voluntarily consent to evaluation and treatment by The Integra Clinic, including but not limited to laboratory testing, hormone therapy, nutritional and lifestyle guidance, and other services as recommended by my provider. I understand I may ask questions and decline any recommended treatment at any time.

I understand The Integra Clinic's pricing is as published on its website (including the free consultation, new patient package, membership, and à la carte visit fees), that payment is due at the time of service unless otherwise agreed in writing, and that laboratory or pharmacy costs billed by third parties are separate from clinic fees.

By checking the box below, I confirm I have read and understood this consent and agree to The Integra Clinic's treatment and financial policies.

[DRAFT TEXT] I acknowledge that The Integra Clinic has made available its Notice of Privacy Practices, describing how my health information may be used and disclosed and how I can access it, consistent with applicable privacy law (including HIPAA). I understand I have the right to request a paper copy of this notice at any time.

I understand my health information will only be shared as permitted by law or with my authorization, and that I may contact The Integra Clinic directly with any privacy questions or concerns.

By checking the box below, I confirm I have received and reviewed this acknowledgment.