Telehealth Informed Consent

Last updated 2026

Template notice: this consent is a starting draft for ProSupply RX LLC. Have it reviewed by your legal counsel and medical director before publishing.

By completing a medical intake or purchasing a clinical service through ProSupply RX, you consent to receive care by telehealth from an independent, US-licensed clinician as described below.

What telehealth is

Telehealth is the delivery of health care using electronic communications, including secure messaging, questionnaires, photos, lab results and, where required, phone or video visits. Your clinician will review the information you provide and decide whether treatment is appropriate. In some states a synchronous phone or video visit is required before a prescription can be written.

Benefits and limits

  • Telehealth gives you access to licensed clinicians without a waiting room, on your schedule.
  • A physical examination is not performed. Your clinician relies on the accuracy and completeness of the information you provide.
  • Telehealth is not appropriate for every condition. Your clinician may decide that in-person care is needed and decline to prescribe.
  • Electronic communications can fail or be delayed. Telehealth is not for emergencies. If you have a medical emergency, call 911.

Your responsibilities

You agree to provide truthful, complete and current information about your health, medications, allergies and history, to follow the instructions in your portal, to report side effects, and to complete any labs your clinician requires. You agree to use the Services only for yourself.

Compounded medications

Some therapies are compounded by US-licensed pharmacies for an individual patient. Compounded medications are not FDA-approved finished products and have not been evaluated by the FDA for safety or effectiveness. Your clinician will explain the risks, benefits and alternatives of any therapy prescribed.

Privacy

Your health information is handled under our HIPAA Notice of Privacy Practices and Privacy Policy. All clinical communication takes place inside the secure member portal.

Your rights

You may withhold or withdraw consent to telehealth at any time without affecting your right to future care. You may ask questions about any aspect of your treatment and request a copy of your records. Your clinician's name, credentials and state license are available on request.

Questions: [email protected]