Telehealth Consent & Informed Consent Disclosure

This disclosure describes how Iron IV provides healthcare services through telehealth, along with the risks, benefits, and terms associated with telehealth and treatment. Patients review and acknowledge this consent as part of the intake process before receiving care.

Telehealth Consent

I understand that Iron IV offers healthcare services through telehealth technology, which allows me to consult with a licensed healthcare provider using electronic communications, including video conferencing, telephone, secure messaging, and other telecommunications technologies.

I understand that telehealth may be used for:

• Medical consultations
• Wellness evaluations
• Weight management consultations
• Review of laboratory results
• Treatment planning and follow-up care
• Prescription management when clinically appropriate

Nature of Telehealth Services

I understand that telehealth services involve communication between me and my healthcare provider who may not be physically present in the same location.

I understand that my provider may determine that an in-person examination, additional testing, or referral to another healthcare professional is necessary before treatment can be recommended.

Provider Licensure and State Requirements

Telehealth services are provided only in states where the treating healthcare provider is licensed and authorized to practice. Prescriptions are issued only when clinically appropriate and in accordance with applicable federal and state laws.

I understand that my provider may not be able to provide services if I am located in a state where the provider is not licensed or otherwise authorized to practice.

Risks of Telehealth

I understand that telehealth services have potential risks, including:

• Technical failures or interruptions
• Poor video or audio quality
• Unauthorized access despite reasonable security measures
• Incomplete information due to limitations of remote assessment
• Delays in treatment due to technology issues
• The inability to perform certain aspects of a physical examination remotely

I understand that no guarantees can be made regarding diagnosis, treatment recommendations, or treatment outcomes.

Benefits of Telehealth

Potential benefits include:

• Improved access to healthcare services
• Convenience and reduced travel time
• More timely consultations and follow-up care
• Greater continuity of care

Emergency Situations

I understand that telehealth services are not intended for emergency medical conditions.

If I experience a medical emergency, I will call 911 or seek immediate medical attention at the nearest emergency department.

I understand that Iron IV providers may not be available for emergency communications or urgent medical situations.

Privacy and Confidentiality

I understand that Iron IV takes reasonable precautions to protect my personal health information and complies with applicable privacy and security laws.

I understand that electronic communications may carry certain risks despite security safeguards and that no electronic system can be guaranteed to be completely secure.

Consent to Treatment

I voluntarily consent to receive healthcare services through telehealth technology.

I understand that I may withdraw my consent to telehealth services at any time by notifying Iron IV in writing, although doing so may limit my ability to receive certain services.

Informed Consent for Treatment

I understand that all treatments recommended by Iron IV are subject to a medical evaluation and provider approval.

I acknowledge and agree that:

• Treatment recommendations are based on information I provide and available medical records.
• I am responsible for providing complete, accurate, and truthful health information.
• Failure to disclose relevant medical information may affect treatment safety and outcomes.
• Individual results vary and cannot be guaranteed.
• No guarantee or warranty has been made regarding the effectiveness of any treatment, therapy, medication, supplement, hormone therapy, or wellness service.

Prescriptions and Laboratory Testing

I understand that:

• Prescriptions may only be issued when medically appropriate and legally permitted.
• Laboratory testing may be required before, during, or after treatment.
• Providers may modify, delay, or discontinue treatment plans based on clinical findings, laboratory results, safety concerns, or changes in my health status.
• Certain medications, therapies, or treatments may not be appropriate for every patient.

Financial Responsibility

I understand that I am responsible for all fees associated with telehealth consultations, laboratory testing, prescriptions, medications, and treatment services unless otherwise stated in writing.

I understand that consultation fees may be non-refundable once services have been provided.

Consent Acknowledgment

By acknowledging this disclosure during intake, the patient confirms that:

• They have read and understood this Telehealth Consent and Informed Consent Disclosure.
• They have had the opportunity to ask questions regarding telehealth services and treatment recommendations.
• Their questions have been answered to their satisfaction.
• They voluntarily consent to participate in telehealth services provided by Iron IV.
• They understand the risks, benefits, and limitations of telehealth services.
• They understand that telehealth does not replace emergency medical care.

A signed copy of this consent is completed with your provider as part of the intake process. To request a copy or ask questions, contact us at contact@ironiv.com or 435-218-4737.