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Telehealth Consent

Telehealth Consent Form

Effective Date: January 1, 2025 ยท Last Updated: December 2025

Contents

  1. Purpose of Telehealth
  2. How Telehealth Works
  3. Benefits of Telehealth
  4. Risks and Limitations
  5. Patient Rights
  6. Privacy & Confidentiality
  7. Technical Requirements
  8. Patient Responsibilities
  9. Medications
  10. Emergency Situations
  11. Consent & Agreement
  12. Withdrawal of Consent
  13. Contact Information
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Licensed Physicians
State Compliant
Prescription Not Guaranteed

Completing a consultation and paying for services does NOT guarantee that a prescription will be issued. Our healthcare providers have sole and absolute discretion to prescribe, modify, or decline any treatment based on their professional medical judgment.

Our healthcare providers may, in their sole discretion, decline to prescribe medication, recommend alternative treatments, or require additional information or in-person evaluation before treatment.

1

Purpose of Telehealth

WellMensRX, operated by Epiq Health, provides telehealth services for the treatment of erectile dysfunction (ED) and related men's health conditions. Telehealth allows you to consult with licensed healthcare providers remotely using secure online platforms, without the need for an in-person office visit.

This document explains what telehealth is, how we use it to deliver care, and what you should know before consenting to treatment. Please read this entire consent form carefully. By proceeding with our services, you acknowledge that you have read, understood, and agree to these terms.

What is Telehealth?

Telehealth is the delivery of healthcare services through electronic communication and information technology when you and your healthcare provider are not in the same physical location. This may include asynchronous consultations (questionnaires and messaging) and secure communication platforms.

2

How Telehealth Works

WellMensRX provides asynchronous telehealth consultations for erectile dysfunction treatment. This means you will complete a comprehensive medical questionnaire, and a licensed physician in your state will review your information and make a determination about your treatment eligibility.

Our Services Include:

  • Comprehensive medical intake questionnaire and health assessment
  • Review of your medical history, current medications, and health conditions
  • Evaluation by a U.S. licensed physician in your state of residence
  • Prescription of compounded medications when medically appropriate
  • Ongoing messaging and consultation for treatment adjustments
  • Access to licensed healthcare providers for questions and support

All physicians providing services through WellMensRX are licensed and authorized to practice medicine in your state. Prescriptions are issued only after a thorough medical evaluation determines that treatment is appropriate and safe for you.

3

Benefits of Telehealth

Telehealth offers several advantages for men seeking ED treatment:

  • Convenience: Complete your consultation from anywhere, without taking time off work or traveling to a medical office
  • Privacy: Discuss sensitive health matters discreetly from the comfort of your own home
  • Accessibility: Access specialized care that may not be readily available in your local area
  • Time Efficiency: Avoid waiting rooms and schedule consultations around your life
  • Continuity of Care: Maintain ongoing communication with healthcare providers for treatment adjustments
  • Discreet Delivery: Medications are shipped directly to your home in unmarked, discreet packaging

Telehealth has been proven effective for many conditions, including ED, and can provide the same quality of care as in-person consultations when used appropriately.

4

Risks and Limitations

While telehealth is safe and effective for many patients, there are certain limitations and potential risks you should understand:

Limitations of Telehealth

  • The provider cannot perform a physical examination or conduct in-person diagnostic tests
  • Assessment relies on the accuracy and completeness of the information you provide
  • Certain complex or urgent medical conditions may require in-person evaluation
  • Technology failures or connectivity issues may occasionally disrupt communication
  • Telehealth may not be appropriate for all patients or all medical conditions

Medical Risks

  • Misdiagnosis or delayed diagnosis if critical information is not provided or available
  • Medication side effects or adverse reactions (similar to in-person care)
  • Treatment may not be effective for all patients
  • Underlying medical conditions contributing to ED may not be identified without comprehensive in-person evaluation
In-Person Referrals

If your provider determines that your condition requires in-person evaluation, laboratory testing, or specialized care, you will be referred to an appropriate healthcare facility. You are responsible for following up on these referrals.

Alternatives to Telehealth

You have the right to choose how you receive healthcare services. Alternatives include:

  • In-Person Consultation: Visit a urologist, primary care physician, or men's health specialist for a face-to-face consultation
  • Your Primary Care Provider: Discuss ED treatment with your existing doctor who has access to your complete medical history
  • Specialist Care: See a urologist or sexual medicine specialist for comprehensive evaluation
  • Mental Health Support: If ED has psychological causes, a therapist or sex therapist may be appropriate
5

Patient Rights

As a patient receiving telehealth services, you have the following rights:

  • Right to Withdraw Consent: You may withdraw your consent for telehealth services at any time without affecting your right to future care
  • Right to Access Your Medical Records: You can request copies of your medical records at any time in accordance with HIPAA regulations
  • Right to Privacy: Your consultations and medical information will be kept confidential in accordance with privacy laws
  • Right to Ask Questions: You may ask questions about your diagnosis, treatment options, medications, or any aspect of your care
  • Right to a Second Opinion: You may seek a second opinion from another healthcare provider at any time
  • Right to Refuse Treatment: You have the right to decline any recommended treatment or medication
  • Right to Know Provider Credentials: You can request information about your provider's qualifications, licensure, and credentials

If you have concerns about your care or wish to file a complaint, please contact our patient support team. We are committed to addressing your concerns promptly and professionally.

6

Privacy and Confidentiality

Your privacy is our top priority. WellMensRX is fully compliant with the Health Insurance Portability and Accountability Act (HIPAA) and all applicable state and federal privacy laws.

How We Protect Your Information

  • All consultations and medical records are stored on secure, HIPAA-compliant servers
  • Communication between you and your provider is encrypted
  • Your personal health information is never sold or shared with third parties for marketing purposes
  • Only authorized healthcare providers and necessary staff have access to your medical information
  • Medications are shipped in discreet, unmarked packaging to protect your privacy

When We May Disclose Information

  • To your pharmacy to fill prescriptions
  • To billing and payment processors to process transactions
  • When required by law (court orders, legal investigations, public health reporting)
  • To prevent imminent harm to you or others

For complete details about how we collect, use, and protect your information, please review our Privacy Policy.

7

Technical Requirements

To use WellMensRX telehealth services, you will need:

  • A device with internet access (computer, tablet, or smartphone)
  • A valid email address for account creation and communication
  • A secure internet connection (we recommend using a private network, not public Wi-Fi)
  • An updated web browser (Chrome, Safari, Firefox, or Edge)

Security Measures

We use industry-standard security protocols to protect your information, including SSL encryption, secure data storage, and HIPAA-compliant communication platforms. However, you are responsible for maintaining the security of your account credentials and using secure internet connections when accessing our services.

Technology Limitations

You acknowledge that telehealth services depend on technology that may experience failures, interruptions, or security vulnerabilities. WellMensRX and its providers shall not be liable for any harm arising from technology failures, including but not limited to internet outages, software malfunctions, or unauthorized access to transmissions.

Technology Issues

If you experience technical difficulties accessing our platform or communicating with your provider, please contact our support team at support@wellmensrx.com.

8

Patient Responsibilities

To ensure safe and effective treatment, you agree to the following responsibilities:

  • Provide Accurate Information: You must provide complete, honest, and accurate information about your medical history, current medications, supplements, health conditions, and symptoms. Incomplete or inaccurate information may result in unsafe treatment recommendations.
  • Drug Interaction Disclosure: You are solely responsible for disclosing ALL medications, supplements, and health conditions to your provider. Failure to disclose may result in dangerous drug interactions. Our medications, including those containing nitrates, PDE5 inhibitors, or other active compounds, may have serious or life-threatening interactions with other substances.
  • Update Your Information: Notify us immediately if there are any changes to your health status, medications, or contact information.
  • Follow Medical Advice: Take medications exactly as prescribed and follow all instructions provided by your healthcare provider.
  • Report Side Effects: Contact your provider immediately if you experience any adverse reactions, side effects, or unexpected symptoms.
  • Attend Follow-Up: Respond to provider messages and complete any requested follow-up consultations or assessments.
  • Secure Your Account: Keep your login credentials confidential and use secure internet connections when accessing our services.
  • Seek Emergency Care When Needed: Understand that telehealth is not appropriate for emergency situations. Seek in-person emergency care when necessary.
Accurate Information Required

Providing false or misleading information to obtain prescription medications is illegal and may result in termination of services and potential legal consequences.

Follow-up Care

Ongoing monitoring and follow-up are important components of safe, effective treatment:

  • Regular Check-Ins: Your provider may schedule periodic check-ins to assess treatment effectiveness
  • Respond to Provider Messages: Reply to messages from your provider in a timely manner
  • Report Treatment Outcomes: Let your provider know how you are responding to treatment
  • Update Health Changes: Inform your provider of any new health conditions or medications
  • In-Person Referrals: If your provider recommends in-person evaluation, follow through with these referrals
9

Medications and Prescriptions

If your provider determines that medication is appropriate for your condition, you will receive a prescription that is filled by a licensed pharmacy or compounding facility.

Controlled Substances

In compliance with DEA regulations and state law, our providers do not prescribe controlled substances (Schedule I-V) through telehealth consultations. If you require controlled substances, you must seek care from an in-person provider.

About Your Medications

  • Medications may include brand-name drugs, generic equivalents, or compounded formulations
  • Compounded medications are prepared by state-licensed pharmacies in accordance with federal regulations
  • Compounded medications are not FDA-approved and have not undergone FDA review for safety, effectiveness, or quality
  • Your provider will determine which medication and formulation is most appropriate for your needs

Medication Safety

  • Take medications exactly as prescribed; do not exceed the recommended dose
  • Do not take ED medications if you use nitrate medications or certain other drugs (your provider will screen for contraindications)
  • Do not share your medications with others
  • Store medications in a cool, dry place away from children and pets
  • Report any side effects to your provider immediately

Prescription Transfers and Refills

Prescriptions issued through WellMensRX are generally filled by our partner pharmacies for convenience. If you wish to transfer a prescription to your local pharmacy, contact our support team for assistance.

10

Emergency Situations

Telehealth services are not appropriate for medical emergencies. WellMensRX does not provide emergency medical care.

Emergency Medical Situations

If you are experiencing a medical emergency, call 911 immediately or go to your nearest emergency room.

Emergency Care Limitations

You understand that telehealth is NOT appropriate for medical emergencies. By using our services, you waive any claims against WellMensRX and its providers for harm arising from emergency situations, delayed care, or your failure to seek immediate emergency treatment when warranted.

Examples of Emergencies Requiring Immediate In-Person Care

  • Chest pain, pressure, or discomfort
  • Difficulty breathing or shortness of breath
  • Severe allergic reaction (difficulty breathing, swelling of face or throat, rapid heartbeat)
  • Erection lasting longer than 4 hours (priapism) - seek emergency care immediately
  • Sudden vision or hearing loss
  • Severe dizziness, fainting, or loss of consciousness
  • Any symptoms you believe require immediate medical attention

After-Hours Support

While our providers are not available 24/7 for emergencies, you can send messages through your patient portal at any time. Non-urgent messages will be responded to within 1-2 business days. For urgent but non-emergency medical concerns, contact your primary care provider or visit an urgent care facility.

11

Consent and Agreement

By proceeding with WellMensRX telehealth services, you acknowledge and agree to the following:

I Understand and Agree That:
I have read and understood this entire Telehealth Consent Form
I have had the opportunity to ask questions about telehealth services and my questions have been answered to my satisfaction
I understand the benefits, risks, and limitations of telehealth services as described in this document
I understand that telehealth services may not be appropriate for all medical conditions and that in-person evaluation may be necessary
I consent to receiving healthcare services through asynchronous telehealth consultation
I will provide complete, accurate, and truthful information about my medical history and current health status
I will follow all instructions provided by my healthcare provider and take medications only as prescribed
I understand that my medical information will be kept confidential in accordance with HIPAA and applicable privacy laws
I authorize WellMensRX and its healthcare providers to use and disclose my health information for treatment, payment, and healthcare operations
I understand that I have the right to withdraw my consent for telehealth services at any time
I understand that in emergency situations, I must call 911 or go to the nearest emergency room
I have reviewed and agree to WellMensRX's Terms of Service and Privacy Policy

Your electronic signature or continued use of WellMensRX services constitutes your acceptance of these terms and your consent to receive telehealth services.

12

Withdrawal of Consent

You have the right to withdraw your consent for telehealth services at any time. Withdrawal of consent will not affect:

  • Your right to future healthcare services
  • Any services already rendered prior to withdrawal
  • Your ability to seek care through other means (in-person visits, other providers)

How to Withdraw Consent

To withdraw your consent for telehealth services, you may:

  • Send an email to support@wellmensrx.com with your request
  • Contact our patient support team by phone
  • Submit a written request through your patient portal

Upon receiving your withdrawal request, we will confirm receipt and discontinue telehealth services. You may request copies of your medical records at any time, in accordance with HIPAA regulations.

13

Contact Information

If you have questions about this Telehealth Consent Form or need assistance with our services, please contact us:

Patient Support
support@wellmensrx.com
Privacy Officer
privacy@wellmensrx.com

We are committed to providing you with safe, effective, and convenient healthcare. Thank you for choosing WellMensRX.

WellMensRX

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