Telemedicine Informed Consent

Effective date: [EFFECTIVE DATE]

Please read this Telemedicine Informed Consent ("Consent") carefully before you request or receive any care through Onsavo. This Consent explains what telemedicine is, how care through Onsavo works, and the benefits, limitations, and risks involved. You must read, understand, and agree to this Consent before an independent provider will review your intake. If you do not agree, do not submit an intake or request care.

This Consent should be read together with our Terms & Conditions, Privacy Policy, Notice of Privacy Practices, Refund & Cancellation Policy, and Disclaimers. Nothing in this Consent is medical advice. Whether any treatment is appropriate for you is a decision made solely by a licensed provider based on your individual health information.

Onsavo is a self-pay telemedicine platform operated by [ONSAVO LEGAL ENTITY]. Onsavo is not a medical practice and is not a pharmacy. Independent, state-licensed healthcare providers affiliated with [AFFILIATED MEDICAL GROUP] review patient intake through telemedicine and, when clinically appropriate, may issue a prescription. Prescribed medications are dispensed by an independent partner compounding pharmacy, [COMPOUNDING PHARMACY] (a 503A/503B pharmacy). Where lab testing is part of a program, at-home labs are processed by [CLIA LAB PARTNER], a CLIA-certified laboratory.

1. What Telemedicine Is and How Onsavo's Service Works

Telemedicine (also called telehealth) is the delivery of healthcare services using electronic communications and information technology, rather than an in-person, face-to-face visit. Through telemedicine, a licensed provider can review your health information, communicate with you, evaluate your needs, and — when clinically appropriate — diagnose, recommend, or prescribe treatment, all without you and the provider being in the same physical location.

Care through Onsavo generally works as follows:

You create an account and complete an online health questionnaire (your "intake") about your health goals, medical history, current medications, allergies, and related information. For some programs, you may be asked to provide your height and weight (used to calculate BMI as one screening measure) or to complete at-home laboratory testing through [CLIA LAB PARTNER].
An independent, state-licensed provider affiliated with [AFFILIATED MEDICAL GROUP] reviews your intake through telemedicine.
Depending on your state, the program, and the provider's clinical judgment, this review may be asynchronous (sometimes called "store-and-forward," in which the provider reviews your written intake and any lab results on their own schedule and responds in writing) or may include a live consultation by phone or video. The provider may also contact you with follow-up questions before making a decision.
If the provider determines that treatment is clinically appropriate and writes a prescription, that prescription is sent to [COMPOUNDING PHARMACY] to be dispensed and shipped to you.
Where you are accepted into a program, your care may continue on an ongoing, provider-guided basis, which can include follow-up messaging, periodic re-evaluation, and — for certain programs — periodic laboratory monitoring.

By agreeing to this Consent, you understand and accept that some or all of your care may be delivered asynchronously, without a real-time conversation, where that is permitted by the laws of your state and the provider determines it is appropriate.

2. Your Patient–Practitioner Relationship Is With an Independent Provider, Not With Onsavo

Onsavo does not practice medicine, does not diagnose conditions, and does not prescribe medications. Onsavo provides the technology platform and administrative support that allow you to connect with independent providers and pharmacies.

When you receive care, the patient–practitioner relationship is established between you and an independent, state-licensed healthcare provider affiliated with [AFFILIATED MEDICAL GROUP] — not with Onsavo. That relationship is established when a provider reviews your intake and accepts you for evaluation and care through telemedicine, consistent with the laws of your state.

These providers exercise their own independent clinical judgment. They are not employed by Onsavo to reach any particular outcome and are under no obligation to prescribe any medication. The provider — not Onsavo — is responsible for the clinical care you receive. Completing the questionnaire or paying for a subscription does not, by itself, create a patient–practitioner relationship and does not guarantee that one will be established.

3. Patient Identity Verification and Your Duty to Provide Accurate Information

To receive care through telemedicine, you must verify your identity. You agree to provide accurate identifying information, which may include your legal name, date of birth, address, and — where required by law, the provider, or the pharmacy — a government-issued photo identification and confirmation that you are the person completing the intake. You may be asked to re-verify your identity at later points. Care may be delayed or declined if your identity cannot be reasonably verified.

You also confirm that:

You are at least 18 years of age (or the age of majority in your state) and are completing the intake for yourself, not on behalf of another person.
You are physically located in a state where Onsavo and its affiliated providers operate ([STATES SERVED]) at the time you receive care.
The contact information you provide — including your email address, phone number, and shipping address — is current and belongs to you.

You have a duty to provide accurate, complete, and truthful health information. The provider relies entirely on the information you supply to make a safe and appropriate decision, because the provider cannot physically examine you. You agree to disclose your full medical history, all current medications and supplements, allergies, and any other information requested, and to promptly update this information if it changes. Providing incomplete, inaccurate, or false information can lead to an incorrect assessment, an inappropriate or harmful treatment decision, or a determination that treatment is not appropriate, and you accept the risks of doing so.

4. Benefits, Limitations, and Risks of Telemedicine

Potential benefits of telemedicine include greater convenience and access to care, the ability to be evaluated without travel or time away from work, and access to providers and programs that might not otherwise be conveniently available to you.

Telemedicine also has important limitations and risks that you should understand and accept before proceeding:

No physical examination. The provider cannot physically examine you, and in asynchronous care may never see or speak with you in real time. The provider relies on the information you submit and any lab results, which may be less complete than an in-person visit.
Possible misdiagnosis or incomplete assessment. Because there is no hands-on examination, it is possible that a condition could be missed, misdiagnosed, or assessed less accurately than it would be in person. Information available through telemedicine may, in rare cases, lead to an incorrect treatment decision.
Technology failures. Telemedicine depends on electronic systems and internet connectivity. Equipment failures, software problems, poor connections, or delays could disrupt or delay your care, interrupt a consultation, or prevent the timely exchange of information.
Information security risks. Although safeguards are used to protect your information, no method of electronic transmission or storage is completely secure. There is a risk, however small, that information transmitted electronically could be intercepted, accessed, or disclosed without authorization, despite reasonable protections.
Telemedicine may not be appropriate for you. Telemedicine is not suitable for every condition or every patient. The provider may determine, at any point, that telemedicine is not appropriate for your situation and may recommend that you seek in-person care, an in-person examination, or emergency care instead. If that happens, you should follow the provider's recommendation.

You understand these limitations and risks and accept them as part of choosing to receive care through telemedicine.

5. Online Prescribing

If, after reviewing your intake (and any follow-up information or lab results), a provider determines that a medication is clinically appropriate for you, the provider may issue a prescription electronically. That prescription is then dispensed by [COMPOUNDING PHARMACY] and shipped to you.

You understand and agree that:

Prescribing is at the provider's sole discretion and is based on the provider's independent clinical judgment. There is no guarantee that you will be prescribed any medication or accepted into any program. Submitting an intake, completing a questionnaire, or paying for a subscription does not entitle you to a prescription.
A provider may decline to prescribe, may prescribe a different medication, dose, or treatment than you requested or expected, or may recommend a non-prescription approach or in-person care.
You do not select or purchase a specific medication yourself; what is dispensed is determined by the provider's prescription.
You should take any prescribed medication only as directed, and you should not start, stop, or change any prescribed treatment without consulting a licensed provider.

Many of the products available through Onsavo are compounded — including compounded GLP-1 weight management medications, compounded NAD+ products, and certain peptide and hormone formulations. Compounded medications are not FDA-approved and have not been reviewed by the FDA for safety, effectiveness, or quality. Compounded medications are prepared by a licensed pharmacy to meet the needs of an individual patient based on a prescription from a licensed provider. Any reference to a branded, FDA-approved medication is provided for general information only and does not mean that a compounded product is the same as, equivalent to, or a substitute for any branded product.

6. Consent to Electronic Communications and to Care via Telemedicine

By agreeing to this Consent, you voluntarily consent to receive healthcare services through telemedicine, including asynchronous (store-and-forward) and/or live care as described above, where permitted by the laws of your state and where the provider determines it is appropriate.

You also consent to communicate electronically with Onsavo, your provider, and the partner pharmacy and laboratory. This may include email, secure messaging through the platform, text messages, and telephone or video calls, used to deliver your care, send notifications, share results, and provide follow-up. You understand that:

Standard message and data rates may apply, and you can adjust certain non-essential communication preferences as described in our Privacy Policy.
Electronic communications are subject to the limitations and security risks described in Section 4.
The platform's messaging features are not monitored on a real-time or 24/7 basis and must not be used for emergencies.

How your information is collected, used, protected, and shared — including for treatment, payment, and healthcare operations — is described in our Privacy Policy and Notice of Privacy Practices.

7. Emergencies — This Service Is Not for Emergencies

Onsavo and telemedicine are not designed for medical emergencies and do not provide emergency or urgent care.

If you are experiencing a medical emergency, call 911 immediately or go to the nearest emergency room. Do not use the Onsavo website, the messaging features, or any telemedicine communication to request emergency help. Messages sent through the platform are not monitored on a real-time or 24/7 basis, and a delay in response could be harmful.

If you are having thoughts of harming yourself or others, call or text 988 (the Suicide and Crisis Lifeline) or call 911.

8. Your Right to Withdraw Consent

Your participation in telemedicine is voluntary. You have the right to withhold or withdraw this Consent at any time, for any reason, without affecting your right to future care or treatment elsewhere. Choosing not to proceed with telemedicine does not penalize you, though it may mean you cannot receive care through Onsavo.

To withdraw your consent, contact us at [SUPPORT EMAIL] or call [BUSINESS PHONE]. Withdrawing consent stops future telemedicine care through the platform going forward; it does not undo care already provided or apply to information already lawfully created or shared. Withdrawing this Consent does not by itself cancel a subscription or entitle you to a refund — to stop future billing, you must also cancel as described in our Refund & Cancellation Policy. (Subscriptions bill monthly; to avoid being charged for the next cycle, you must cancel at least [X] days before your next monthly billing date.)

9. Medical Records and HIPAA

A record of your telemedicine care — including your intake responses, communications with your provider, prescriptions, and any lab results — is created and maintained as part of your medical record. You have rights with respect to this information, including, in many cases, the right to access a copy of your records, consistent with applicable law.

The information you provide is protected health information (PHI) and is handled in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable privacy laws. How your PHI is used and disclosed, and the rights you have over it, are described in detail in our Notice of Privacy Practices and our Privacy Policy. Please review those documents. Information may be shared among Onsavo, your provider ([AFFILIATED MEDICAL GROUP]), the dispensing pharmacy ([COMPOUNDING PHARMACY]), and the laboratory ([CLIA LAB PARTNER]) as needed to provide your care, process payment, and conduct healthcare operations, consistent with those notices and applicable law.

10. Acknowledgement and Consent

By checking the box, clicking to accept, or otherwise indicating your agreement, you acknowledge and agree that:

You have read and understand this Telemedicine Informed Consent.
You understand what telemedicine is and how care through Onsavo works, including that some care may be delivered asynchronously without a real-time conversation.
You understand that your patient–practitioner relationship is with an independent provider affiliated with [AFFILIATED MEDICAL GROUP], not with Onsavo, and that prescribing is at the provider's sole discretion with no guarantee of a prescription.
You understand and accept the benefits, limitations, and risks of telemedicine described above, including that the provider may determine telemedicine is not appropriate and recommend in-person care.
You understand that compounded medications are not FDA-approved and have not been reviewed by the FDA for safety, effectiveness, or quality.
You agree to verify your identity and to provide accurate, complete, and truthful health information.
You consent to electronic communications and to receiving care via telemedicine where permitted by the laws of your state.
You understand this service is not for emergencies and that you should call 911 in an emergency.
You understand you may withdraw this Consent at any time as described in Section 8.
You have had the opportunity to ask questions, your questions have been answered to your satisfaction, and you voluntarily consent to care through telemedicine.

Effective date of this Consent: [EFFECTIVE DATE].

If you have questions about this Consent before agreeing, contact us at [SUPPORT EMAIL], call [BUSINESS PHONE], or write to us at [BUSINESS MAILING ADDRESS]. For questions about how your information is handled, contact [PRIVACY EMAIL] or [PRIVACY OFFICER NAME/TITLE]. This Consent and your use of the Onsavo services are governed by the laws of the State of [GOVERNING-LAW STATE].

This is a template for [ONSAVO LEGAL ENTITY]; have qualified counsel review before publishing.