Telehealth Informed Consent

This Telehealth Consent explains the nature, benefits, risks, alternatives, and limitations of receiving care through telehealth from Urgent Care Concierge.

Urgent Care Concierge is a telehealth service of The Care Concierge, PLLC. The Care Concierge, PLLC d/b/a Urgent Care Concierge provides cash-pay telehealth visits for adults physically located in Arizona at the time of the visit.

By signing this consent, you agree to receive health care services through telehealth.

What Telehealth Means

Telehealth means health care services are provided using electronic communication technology. This may include video, audio, secure messaging, electronic forms, electronic health records, patient portal communication, images when clinically appropriate, and other electronic tools.

Telehealth allows you to communicate with a medical provider without being physically present in the same location.

Consent to Telehealth

I consent to receive health care services through telehealth from Urgent Care Concierge.

I understand that before care is delivered through telehealth, I must provide informed consent. I understand this consent may be provided electronically.

Nature of the Visit

A telehealth urgent care visit may include:

• Review of my intake information
• Review of my symptoms and relevant history
• Video or audio evaluation
• Medical decision-making
• Treatment recommendations
• Prescriptions when clinically appropriate
• Lab or imaging orders when clinically appropriate
• Work or school notes when medically appropriate
• Instructions for follow-up care
• Recommendation for in-person urgent care, emergency care, specialist care, or primary care follow-up when appropriate

Benefits of Telehealth

Potential benefits include:

• Convenient access to medical care
• Avoiding unnecessary waiting rooms when appropriate
• Same-day or timely evaluation when available
• Clear medical guidance
• Prescriptions, labs, imaging, or work/school notes when clinically appropriate
• Direction to the right level of care when telehealth is not appropriate

Risks and Limitations of Telehealth

I understand telehealth has risks and limitations, including:

• The provider cannot perform a full hands-on physical examination
• Technology may fail or be interrupted
• Video or audio quality may limit evaluation
• Some conditions cannot be safely diagnosed or treated virtually
• The provider may not be able to fully evaluate certain symptoms without in-person exam, vital signs, testing, imaging, or procedures
• Information I provide may be incomplete or inaccurate
• The provider may recommend in-person urgent care, emergency care, labs, imaging, or another level of care
• There may be privacy risks with electronic communication despite reasonable safeguards
• Telehealth may not prevent worsening symptoms or the need for in-person evaluation

Alternatives to Telehealth

I understand I may choose to seek care through:

• Primary care
• In-person urgent care
• Emergency department
• Specialist care
• Another telehealth provider
• No treatment

Arizona Location Requirement

I confirm that I must be physically located in Arizona at the time of the telehealth visit.

I understand that Urgent Care Concierge currently does not provide telehealth visits to patients located outside Arizona.

Adult Patient Requirement

I understand that Urgent Care Concierge currently provides telehealth visits for adults 18 years of age and older.

Not for Emergencies

I understand Urgent Care Concierge is not an emergency service.

I agree not to use Urgent Care Concierge for emergency symptoms, including but not limited to chest pain, severe shortness of breath, stroke-like symptoms, fainting, seizure, severe abdominal pain, severe allergic reaction, major injury, pregnancy-related bleeding or significant pain, suicidal thoughts, testicular pain, eye pain or vision loss, or any potentially life-threatening symptom.

Controlled Substances and Restricted Medications

I understand Urgent Care Concierge does not prescribe controlled substances through this telehealth urgent care service.

This includes opioid pain medications, benzodiazepines, stimulants, controlled cough medications, sedatives, testosterone, and similar restricted medications.

I understand Urgent Care Concierge does not initiate injectable weight-loss medications through this urgent care telehealth service.

Prescriptions Are Not Guaranteed

I understand prescriptions are not guaranteed.

I understand antibiotics are not guaranteed.

I understand medications are prescribed only when clinically appropriate.

I understand many common conditions, including viral illnesses, do not require antibiotics.

Labs, Imaging, and Work Notes Are Not Guaranteed

I understand labs, imaging, referrals, work notes, and school notes are not guaranteed.

They are provided only when medically appropriate based on clinician judgment.

Patient Responsibilities During Telehealth

I agree to:

• Provide accurate and complete information
• Confirm my current physical location at the time of the visit
• Provide a callback number if requested
• Be in a safe, private location during the visit
• Use appropriate technology for the visit
• Not record the visit without written permission
• Tell the provider if anyone else is present during the visit
• Ask questions if I do not understand the care plan
• Follow recommendations or seek the recommended level of care
• Seek emergency care if symptoms become severe, worsening, or potentially life-threatening

Privacy and Confidentiality

I understand my telehealth visit and medical records are protected by applicable privacy laws.

I understand all medical reports and documentation resulting from the telehealth consultation may become part of my medical record.

I understand electronic communication has privacy risks, and I agree to take reasonable steps to participate from a private setting.

Technology Failure

I understand that if the telehealth connection fails or the provider determines the visit cannot be safely completed virtually, the provider may attempt to reconnect, reschedule, convert to another communication method when appropriate, or recommend in-person care.

Provider Right to Redirect Care

I understand the provider may determine that my symptoms are not appropriate for telehealth.

If so, the provider may recommend in-person urgent care, emergency evaluation, lab testing, imaging, specialist care, or primary care follow-up.

I understand that refusal to follow the provider’s recommendation may carry medical risk.

48-Hour Same-Issue Clarification Window

I understand that the visit fee includes one 48-hour same-issue clarification window.

This is intended for brief clarification about the same concern addressed during the visit.

It is not for new symptoms, worsening symptoms, new medical concerns, emergencies, medication refills unrelated to the visit, repeated back-and-forth messaging, or ongoing chronic care.

New symptoms, worsening symptoms, red-flag symptoms, or a new concern may require a new visit, in-person urgent care, or emergency evaluation.

Consent to Treat

I consent to evaluation and treatment through telehealth by Urgent Care Concierge.

I understand that treatment may include medical advice, prescriptions when clinically appropriate, lab or imaging orders when clinically appropriate, and referral to another level of care when appropriate.

Questions

I have had the opportunity to ask questions about telehealth, its risks, benefits, alternatives, limitations, privacy considerations, and payment policies.

Patient Acknowledgment and Consent

By signing below, I acknowledge and agree that:

• I have read and understand this Telehealth Consent
• I consent to receive care through telehealth
• I understand telehealth has limitations
• I understand Urgent Care Concierge is not an emergency service
• I understand I must be physically located in Arizona
• I understand this service is for adults 18 and older
• I understand controlled substances are not prescribed through this service
• I understand prescriptions, antibiotics, labs, imaging, and work/school notes are not guaranteed
• I understand the provider may recommend in-person urgent care, emergency care, or another level of care

Patient/Responsible Party Name: _______________________________

Signature: _______________________________

Date: _______________________________