Naltrexone for Alcohol Use Disorder — Telemedicine Consent

Last updated: September 2026

DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY. In an emergent situation, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (1-800-273-8255); or (v) if applicable, contact the Crisis Text Line (text "GO" to 741-741).

We are pleased you have chosen MDI Medical Group PC and its affiliated medical practices (collectively the "MDI Practices") for your telemedicine evaluation and treatment of alcohol use disorder (AUD) with naltrexone. This document is intended to inform you of what you can expect of your clinician in terms of his or her credentials and in connection with this treatment via telemedicine, and to explain the specific benefits, risks, and requirements of naltrexone treatment for AUD. After you have carefully read this document and had an opportunity to have your questions answered, certain state laws mandate that you must sign and date it before commencing services.

Your Telehealth Provider's Credentials

Your provider's credentials will be made available to you as part of your telehealth visit. If you have any questions about these credentials, please direct them to your telehealth provider. For those states that require it, you can find an explanation of the levels of regulation applicable to telehealth clinicians under the STATE REGULATIONS section at the end of this document.

Important Information Regarding Your Treatment by Telehealth Providers, Including Potential Risks and Benefits

The MDI Practices offer treatment by various types of healthcare providers via telecommunications technology (also referred to as "telehealth"). Our providers include physicians, nurses, and equivalent licensed professionals. The services provided may also include chart review, remote prescribing, appointment scheduling, refill reminders, health information sharing, and non-clinical services, such as patient education. The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. There are various benefits associated with telehealth services, including improved access to care by enabling you to remain in your home while the provider consults with you, more efficient care evaluation and management, and obtaining expertise of a specialist as appropriate. Possible risks include delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, and in rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.

By typing your name into the appropriate field on your intake form it will be interpreted as your electronic signature and you are representing that you have read this document and understand the information found in it.

At times, your clinician may seek supervision or consultation with other MDI Practice or non-MDI Practice clinicians regarding your treatment, to enhance the services being provided to you given the multiple perspectives, experiences, and treatment philosophies. All team members are ethically and legally bound to maintain your privacy and confidentiality in this scenario and none of your personal information will be shared or disclosed with any other individual without your consent. Exceptions to confidentiality do exist in certain situations, such as: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; permission from the client or guardian (i.e. voluntary release signed by the client or guardian); during supervisory consultations; diagnosis and dates of service shared with an insurance company to collect payments; information released as outlined by any applicable Privacy Policies; and as otherwise required by law.

Treatment and Confidentiality of Minors

In accordance with state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor. If the parents of a minor are separated, treatment is provided to the minor only with the consent of both parents. If the parents of the minor are divorced, consent for treatment of the minor may be given by the parent authorized to make medical decisions for the minor. If a court of law has ordered that medical decisions for the minor are to be made jointly by the minor's parents, then consent of both parents is required for treatment of the minor. In the case of minors, as defined by state law, parents may request information about their child's diagnosis or treatment. While release of this information will be provided, it is best that the process be a collaborative one involving the minor, parent, and clinician in order to maintain the rapport established between the minor and clinician since rapport is vital to treatment success. Therefore, unless there is a safety concern, the minor would be consulted about the disclosure and encouraged to share the information with the parent first in order to establish better communications within the family structure.

Naltrexone Treatment Information

Purpose and Treatment Expectations. You understand that naltrexone is used to help treat alcohol use disorder and may help reduce alcohol cravings and alcohol consumption. Individual response varies, and treatment does not guarantee abstinence or elimination of cravings. You understand that naltrexone is one component of treatment and that counseling, behavioral treatment, recovery support, and/or other medical or mental health services may also be recommended.

Alcohol Withdrawal. You understand that naltrexone does not treat or prevent acute alcohol withdrawal. Suddenly stopping or substantially reducing alcohol after regular or heavy alcohol use can cause withdrawal, which may become severe or life-threatening. You agree to seek immediate emergency medical care for seizures, hallucinations, severe confusion or disorientation, severe agitation, persistent or severe vomiting, loss of consciousness, or other severe or rapidly worsening withdrawal symptoms rather than attempting to manage these symptoms through the telehealth platform.

Opioid Use and Precipitated Withdrawal. You understand that naltrexone blocks opioid receptors and must not be started while you are currently using opioid medications or drugs, physically dependent on opioids, or experiencing opioid withdrawal. Taking naltrexone too soon after opioid use can cause sudden and potentially severe opioid withdrawal that may require hospitalization. You agree to accurately disclose all recent opioid use, including prescription pain medications, tramadol, methadone, buprenorphine, opioid-containing cough or antidiarrheal medications, heroin, fentanyl, and other prescribed or nonprescribed opioids. If you have previously used or been dependent on short-acting opioids, you attest that you have been completely opioid-free, including tramadol, for at least 7–10 days before starting naltrexone. You understand that transitioning from methadone or buprenorphine may require a longer opioid-free period and must be disclosed to your treating clinician. You agree not to start naltrexone if you are experiencing opioid withdrawal or are uncertain whether you have been opioid-free for an adequate period.

Opioid Blockade and Overdose Risk. You understand that while taking naltrexone, opioid-containing pain medications and other opioid-containing products may not have their expected effects. You agree not to attempt to overcome the opioid-blocking effects of naltrexone by taking larger amounts of opioids, and you understand that doing so can cause serious injury, overdose, coma, or death. You understand that after naltrexone is stopped or interrupted, your tolerance to opioids may be reduced, and an amount of opioid you previously tolerated could result in a life-threatening or fatal overdose. You understand the importance of having access to an opioid-overdose reversal medication, such as naloxone, and that 911 or emergency medical care is still required for a known or suspected opioid overdose even if an opioid-overdose reversal medication is administered.

Surgery, Procedures, Emergency Care, and Pain Treatment. You agree to tell any physician, dentist, surgeon, emergency medical professional, or other healthcare professional treating you that you are taking naltrexone before receiving pain medication, undergoing surgery or a procedure, or receiving emergency medical treatment. You understand that naltrexone can interfere with opioid pain medications and may affect how pain must be managed. For planned surgery or procedures, you agree to contact your treating clinician and procedural team in advance when possible. You will not stop, restart, or alter naltrexone on your own solely to permit opioid use. You understand that carrying or maintaining medical identification indicating that you take naltrexone may help healthcare professionals provide appropriate treatment in an emergency.

Liver Safety. You understand that hepatitis and clinically significant liver dysfunction have been reported with naltrexone. You agree to promptly contact your clinician and seek appropriate medical evaluation if you develop signs and symptoms of liver injury, including yellowing of the skin or eyes, dark urine, or persistent upper abdominal pain. You understand that your clinician may determine that laboratory testing, additional evaluation, treatment interruption, or another treatment option is appropriate based on your medical history or symptoms.

Mental Health Safety. You understand that depression, suicidal thoughts, suicide attempts, and suicide have been reported in patients receiving naltrexone, although a causal relationship has not been established. You agree to promptly report significant new or worsening depression, mood or behavioral changes, or suicidal thoughts. If you believe you may harm yourself or someone else, or you are otherwise in immediate danger, you understand that you should call 911 or seek immediate emergency care rather than waiting for a response through the telehealth platform.

Other Medication and Safety Considerations. You agree to inform your treating clinician of all prescription medications, over-the-counter medications, vitamins, supplements, and recreational or nonprescribed substances you use and of any significant changes during treatment. You understand that dizziness or other side effects may occur, and you will not drive, operate machinery, or perform potentially hazardous activities until you know how the medication affects you. You agree to promptly report significant or unexpected medication reactions.

Limitations of Telemedicine Assessment. You understand that telemedicine, including asynchronous care, relies substantially on the accuracy and completeness of the information you provide and does not provide continuous monitoring or the same physical examination and immediate diagnostic testing available during in-person care. You understand that completing an online questionnaire or this consent does not guarantee that naltrexone will be prescribed or continued. Your clinician may determine that additional information, laboratory testing, synchronous telehealth evaluation, in-person examination, emergency evaluation, specialty care, or another level of care is necessary before prescribing or continuing treatment. You agree to provide complete and accurate information regarding your alcohol use, opioid and other substance use, medications, medical conditions, mental health history, withdrawal history and symptoms, and other information relevant to treatment safety.

Patient Acknowledgment

By typing your name into the appropriate field on your intake form, it will be interpreted as your electronic signature, and you acknowledge that you understand and agree to the following:

1. You consent to receiving evaluation and, if clinically appropriate, treatment for alcohol use disorder with naltrexone from the MDI Practices via telehealth technologies. You understand that the MDI Practices and its providers offer telehealth-based medical services, but these services do not replace the relationship between you and your primary care provider. You understand that it is the MDI Practice provider's responsibility to determine whether your clinical needs are appropriate for telehealth and whether naltrexone is medically appropriate for you. Completing an intake or providing consent does not guarantee that naltrexone or any other medication will be prescribed.
2. You acknowledge that you have reviewed and understand this consent, have had the opportunity to ask questions about naltrexone treatment for alcohol use disorder, and understand the potential benefits, risks, limitations, and alternatives to treatment.
3. You understand that naltrexone does not treat or prevent acute alcohol withdrawal and that alcohol withdrawal can become severe or life-threatening. You understand when telehealth is not an appropriate substitute for urgent or emergency medical care and agree to seek immediate in-person emergency medical treatment or call 9-1-1 for seizures, hallucinations, severe confusion, loss of consciousness, or other severe or rapidly worsening withdrawal symptoms. You understand that MDI Practice providers cannot connect you directly to local emergency services.
4. You understand that naltrexone can cause sudden and potentially severe opioid withdrawal if taken while opioids remain in your body or if you are physically dependent on opioids. You agree to accurately disclose all current and recent opioid use and any history of opioid dependence. If you have previously used or been dependent on short-acting opioids, you attest that you have been completely opioid-free, including tramadol, for at least 7–10 days before starting naltrexone. You understand that methadone and buprenorphine may require a longer opioid-free period and must be disclosed to your treating provider. You agree not to start naltrexone if you are experiencing opioid withdrawal or are uncertain whether you have been opioid-free for an adequate period.
5. You understand that naltrexone blocks the effects of opioids and may interfere with opioid-containing pain medications and other opioid-containing products. You agree not to attempt to overcome this blockade by taking larger amounts of opioids because doing so can result in serious injury, overdose, coma, or death. You also understand that after naltrexone is stopped, interrupted, or missed, your tolerance to opioids may be reduced and an amount of opioid you previously tolerated could result in a life-threatening or fatal overdose.
6. You agree to inform physicians, dentists, surgeons, emergency medical professionals, and other healthcare professionals treating you that you are taking naltrexone before receiving pain medication, undergoing surgery or a procedure, or receiving emergency medical treatment. You will not stop, restart, or alter naltrexone on your own solely to permit opioid use.
7. You understand that liver problems have been reported with naltrexone and agree to promptly notify your treating provider and seek appropriate medical evaluation for signs and symptoms of liver injury, including yellowing of the skin or eyes, dark urine, or persistent upper abdominal pain. You also agree to promptly report significant new or worsening depression, mood or behavioral changes, or suicidal thoughts and to seek immediate emergency assistance if you believe you may harm yourself or someone else.
8. You understand that naltrexone is one component of treatment for alcohol use disorder. Individual response varies, and no result can be guaranteed, including abstinence, reduction in alcohol use, or elimination of alcohol cravings. Counseling, behavioral treatment, recovery support, and/or other medical or mental health services may also be recommended.
9. You acknowledge that telehealth, including asynchronous care, relies substantially on the accuracy and completeness of the information you provide and does not provide continuous monitoring or the same physical examination and immediate diagnostic testing available through in-person medical care. You agree to provide complete and accurate information regarding your alcohol use, opioid and other substance use, medications, medical conditions, mental health history, withdrawal history, current symptoms, and other information relevant to treatment safety. Your provider may require additional information, laboratory testing, synchronous telehealth evaluation, in-person evaluation, specialty care, or another level of care before prescribing or continuing treatment.
10. You have been given an opportunity to review your provider's credentials.
11. You understand that federal and state law requires healthcare providers to protect the privacy and security of health information. You understand that the MDI Practices will take steps to protect your health information from unauthorized access and that telehealth may involve electronic communication of your medical information to other healthcare practitioners who may be located in other areas, including out of state.
12. You understand that technical failures may occur during telehealth services that are beyond the control of the MDI Practices and may result in delays or interruptions in communication or transmission of information.
13. You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment. You may suspend or terminate use of telehealth services at any time.
14. You understand that alternatives to telehealth consultation, including in-person medical services, are available to you. You understand that certain components of your care, including laboratory testing or bloodwork, may need to be completed at an outside testing facility at the direction of the MDI Practice provider.
15. You understand that your healthcare information may be shared with authorized individuals as necessary for treatment, healthcare operations, scheduling, and billing. If other individuals are present during a synchronous telehealth consultation to operate telehealth technology or assist with your care, you may ask about their role, request that non-medical personnel leave when appropriate, request that particularly sensitive information not be discussed in their presence, or terminate the consultation.
16. You understand that controlled substances or narcotic medications will not be prescribed through this alcohol use disorder treatment service and that there is no guarantee that you will receive any prescription.
17. You understand that you may request access to or a copy of your medical records in accordance with applicable law and the MDI Practices' policies and may have access to portions of your medical record through the patient portal.
18. You acknowledge that you have read and understand any additional telehealth disclosures applicable to the state in which you are physically located at the time of the telehealth encounter, as provided at the end of this document.

State Regulations

Alaska: You understand your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.63.210(C)(2)).

Arizona: You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (Ariz. Rev. Stat. Ann. § 36-3602(D)).

California: You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment, or, affecting your ability to access covered services from Medi-Cal in the future. You understand that you have the right to access Medi-Cal covered services through an in-person, face-to-face visit or through telehealth. You understand that Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted. (Cal. Welf. & Inst. Code Ann. § 14132.725(d)). Physicians: All physicians licensed to practice in the State of California are licensed and regulated by the Medical Board of California. To check on a physician’s license or to file a complaint, go to www.mbc.ca.gov, email licensecheck@mbc.ca.gov, call (800) 633-2322 or use this QR code:

Connecticut: You understand that your primary care provider may obtain a copy of your records of your telehealth encounter, and that you can revoke your consent at any time. (Conn. Gen. Stat. Ann. § 19a-906).

D.C.: You have been informed of alternate forms of communication between you and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10). Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. (D.C. Mun. Regs. tit. 17, § 4618.9).

Florida: You can view your rights under Florida’s Patient Bill of Rights and Responsibilities, by visiting the Florida Agency for Health Care Administration: https://www.flsenate.gov/laws/statutes/2011/381.026. To view your rights under Florida’s Weight-Loss Consumer Bill of Rights, click here: https://www.flsenate.gov/Laws/Statutes/2015/501.0575.

Georgia: You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).

Idaho: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://dopl.idaho.gov/filing-a-complaint/ (Idaho Guidelines for Appropriate Regulation of Telemedicine). You further understand that your informed consent for the use of telehealth services shall be obtained by applicable law. Idaho Statutes 54-5708.

Indiana: If a prescription is issued to you, and subject to your consent the prescriber shall notify your primary care provider of any prescriptions the prescriber has issued for you if the primary care provider's contact information is provided by you. This requirement does not apply if: (A) The practitioner is using an electronic health record system that your primary care provider is authorized to access. (B) The practitioner has established an ongoing provider-patient relationship with the patient by providing care to the patient at least 2 consecutive times through the use of telehealth services. If the conditions of this clause are met, the practitioner shall maintain a medical record for you and shall notify your primary care provider of any issued prescriptions. Ind. Code Ann. 25-1-9.5-7. If you are a Medicaid patient, you have the right to choose between an in-person visit or telehealth visit. Indiana Medicaid Manual: Telehealth and Virtual Services.

Iowa: To file a complaint, fill out the complaint form and email it to the medical board at ibmcomplaints@iowa.gov. Iowa Admin. Code 653-13.11(147,148,272C)(13.11(18)). As appropriate your provider will identify the medical home or treating physician(s) for you, when available, where in-person services can be delivered in coordination with the telemedicine services. Your provider shall provide a copy of the medical record to your medical home or treating physician(s). Iowa Admin. Code 653-13.11(147,148,272C)(13.11(11))

Kansas: You understand that if you have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to you during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A).

Kentucky: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://kbml.ky.gov/board/Pages/default.aspx. If requested by you, your physician must share the medical record with your primary care physician and other relevant members of your existing care team. Kentucky Board Opinion on the Use of Telemedicine Technologies (2014), as amended September 15, 2022.

Louisiana: You understand the role of other health care providers that may be present during the consultation other than the telehealth provider. (46 La. Admin. Code Pt XLV, § 7511).

Maine: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://www.maine.gov/md/complaint/file-complaint. (Code Me. R. tit. 02-373 Ch. 11, § 3.).

Nebraska: If you are a Medicaid recipient, you retain the option to refuse the telehealth consultation at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation as provided by law for access to your medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05).

New Hampshire: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

New Jersey: You understand that you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. If you do not have a primary care provider or other health care provider of record, the health care provider engaging in telemedicine or telehealth may advise you to contact a primary care provider, and, upon request by you, may assist you with locating a primary care provider or other in-person medical assistance that, to the extent possible, located within reasonable proximity to you. N.J. Rev. Stat. Ann. § 45:1-62.

Ohio: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-37-01(C)(4).

Oregon: If you have a concern or complaint about the providers providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52-677.07. See also Or. Medical Board, Statement of Philosophy: Telemedicine (Oct 2, 2020)

Complaints may be filed with:
Oregon Medical Board
1500 SW 1st Ave., Suite 620
Portland, OR 97201-5847
Complaint Resource Staff: 971-673-2702 | complaintresource@omb.oregon.gov

Rhode Island: If you use e-mail or text-based technology to communicate with your provider, then you understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. You have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. You acknowledge that your failure to comply with this agreement may result in the telehealth provider terminating the relationship. (Rhode Island Medical Board Guidelines).

South Carolina: You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. You understand the value having of having a primary care medical home and, if requested, we can provide assistance in identifying available options for a primary care medical home. S.C. Code Ann. § 40-47-37. You also understand that if you are a Medicaid beneficiary, you can withdraw your consent at any time. South Carolina Health and Human Svcs. Dept. Physicians Provider Manual, p. 35 (Feb. 2024)

South Dakota: You have received disclosures regarding the delivery models and treatment methods or limitations. You have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3).

Tennessee: You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a Medicaid recipient. (TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 8, (2012) (Accessed Jan. 2024)).

Texas: You understand that your medical records may be sent to your primary care physician within 72 hours. Tex. Occ. Code Ann. § 111.005. You have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us

Utah: You are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. Utah Admin. Code r. 156-1-602.

Virginia: You acknowledge that you have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; You agree to hold harmless the MDI Practices for information lost due to technical failures; and you provide your express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).

Vermont: You understand that you have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. You understand that receiving telehealth services via store-and-forward technologies by the MDI Practices does not preclude you from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361).

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; Board of Osteopathic Examiners can be found at: https://sos.vermont.gov/opr/complaints-conduct-discipline/#emr (Vt. Board of Medical Practice, Policy on the Appropriate Use of Telemedicine Technologies in the Practice of Medicine (March 1, 2023).

You have read this document carefully, and understand the risks and benefits of the telehealth services and have had your questions regarding the services explained and you hereby give your informed consent to participate in a telehealth consultation under the terms described herein.

By attesting on the appropriate field on your questionnaire it will serve as your electronic signature for this "INFORMED CONSENT FOR TELEHEALTH SERVICES" you hereby state that you have read, understood, and agree to the terms of this document.