Telehealth Consent

VitaStir Telehealth Consent

You have asked VitaStir to arrange for a licensed physician (“Physician”) to review the health information you provided to VitaStir through its online telehealth platform (the “Service”) to determine what, if any, VitaStir healthy lifestyle products and services are medically appropriate for you (the “Physician Consultation”). The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent for VitaStir and the Physicians to use telehealth to provide you with health care services through the Service.
In this Consent, the words “you” and “yours” means the person using the Service, or in the case of a minor between the ages of 13 and 18 years-old (or a higher age of majority under applicable state law) means both the parent or guardian who provides consent to use the Service by minor and the minor for whom consent is being provided.
Please carefully read all of the information below. By clicking “I Agree” below, by carrying through with the Physician Consultation, or by signifying your acceptance of any other component of the Service means you understand and agree to all of the following:

Telehealth means the use of electronic communication systems and information technology to provide health care services when the patient and the health care provider are not in the same physical location. Telehealth may be used for diagnosis, treatment, prescribing, patient education, and follow-up care, and can be done through phone, electronic transmission of medical records and health information, or by electronic communication between the patient and the provider by audio, visual, audiovisual, or other data transmission, including messaging services or email.
The use of telehealth may have some or all of the following benefits for you: increase your access to health care services; increase the efficiency of health care services, allow you to access health care services at times and places that are convenient for you.
The use of telehealth may also present some or all of the following risks to you: the inability of your health care provider to perform an in-person exam may limit the quality, accuracy or effectiveness of the health care services you receive, and may limit or negatively impact your health care provider’s ability to diagnose your condition and provide you with the care that you need; you may be required to seek alternative sources of medical care; the technology used for telehealth, including the Service, may have errors or bugs that negatively impact the quality and timeliness of health care services provided, the accurate or timely transmission of health care information, the accuracy or completeness of information used to provide health care services, render the technology, including the Service inoperable or unavailable, or cause the loss of health information and/or personal data.
The use of telehealth also involves the risk of possible failures of technology, equipment, electronic systems or security systems and protocols that could result in a loss of your health information or a breach of privacy and unintended disclosure to unauthorized individuals or entities, which may also negatively impact the care you receive by telehealth.
The health care services you receive through use of the Service will be provided to you using telehealth. By starting or continuing to use the Service or by requesting or receiving a Physician Consultation, you consent to the use of telehealth to provide you with health care services.
You understand that at any time a Physician using their independent medical judgement may determine that it is not medically appropriate to provide health care services to you using telehealth or the Service. You agree to discontinue using the Service immediately if the Physician makes such a determination.
You may withdraw your consent to use telehealth for the provision of health care services at any time by providing VitaStir with written notice. Your withdrawal of consent is immediately effective upon VitaStir’s receipt of your written notice but will not impact health care services provided using telehealth prior to VitaStir’s receipt of your notice of withdrawal of consent. Your withdrawal of consent shall not impact any other terms of this Consent, and you must continue to follow the Consent. You understand that withdrawal of consent for telehealth means that VitaStir and the Physicians will no longer be able to provide you with health care services using the Service or otherwise, as neither the Physician nor VitaStir provides in-person health care services.
The Service is not designed to provide you with emergency medical or mental health services.
IF YOU HAVE A MEDICAL EMERGENCY, YOU SHOULD DIAL 911.
IF YOU ARE HAVING A MENTAL HEALTH EMERGENCY OR ARE THINKING ABOUT SUICIDE, YOU SHOULD DIAL THE SUICIDE AND CRISIS LIFELINE AT 988.
VitaStir and its Physicians use software and network security systems and protocols to safeguard the security and privacy of your health information. VitaStir and its Physicians will not release your protected health information to third parties without your consent, except as permitted or required by law. You may receive phone, email, or other electronic communication from VitaStir or a Physician that may contain your protected health information. You acknowledge that VitaStir and the Physicians cannot and do not guarantee the security and privacy of the technology or services or equipment you use to receive such communications.
Neither VitaStir nor the Physician makes any guarantee that you will receive a prescription for a VitaStir product as a result of using the Service or receiving a Physician Consultation.
Neither VitaStir nor the Physician guarantees any specific result if you use the Service or a VitaStir product.
You agree to provide accurate and complete information about yourself and your health when using the Service or communicating with a Physician. There are risks to your health and well-being if you give incorrect or incomplete information. You certify that all of the information you provide to VitaStir and the Physician is true, accurate, and complete.
You understand that the information you provide to the Physician when using the Service or communicating with the Physician might be the only information used by the Physician to provide you with health care services. The Physician will not have access to your health information held by other medical professionals.
The fees you have paid or will pay to VitaStir cover the cost of using the Service, receiving a Physician Consultation, and any VitaStir products prescribed by the Physician. VitaStir and the Physician will not bill your medical insurance company or any other third-party payor for your use of the Service, the Physician Consultation, or the VitaStir products.
You are responsible for arranging and paying for any follow-up care you receive after the Physician Consultation or while or after using the Service.
If the Physician prescribes a product for you, the Physician will send the prescription to a VitaStir affiliated pharmacy for dispensing. VitaStir and the pharmacy will work together to deliver the prescribed products to you at the address you have provided to VitaStir. Please be sure you have provided VitaStir with an address where you may safely and securely receive delivery of the VitaStir products.
By clicking “I Agree” or utilizing the Service, you are consenting to the Physician’s and VitaStir’s sharing of your protected health information with certain third parties, including the pharmacy, as more fully described in VitaStir’s Notice of Privacy Practices, available on the VitaStir website.
Copies of your medical record associated with your use of the Service are available in accordance with applicable law by request to VitaStir.
If you have a concern or complaint about the Physician, please contact the medical licensing board in your state. VitaStir provides contact information for state medical boards on its website.
If you have a concern or complaint about the pharmacy that fills your prescription for a VitaStir product, please contact the pharmacy licensing board in your state. VitaStir provides contact information for state pharmacy boards on its website.

4866-8244-1830.1