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Contact SupportAbout Us

Medical Consent

Last updated: April 14, 2026

WE ARE NOT A REPLACEMENT FOR EMERGENCY MEDICAL SERVICES. IF YOU HAVE A MEDICAL EMERGENCY SEEK EMERGENCY MEDICAL CARE IMMEDIATELY IN-PERSON OR DIAL 911 OR YOUR LOCAL EMERGENCY NUMBER.

We may change these terms at any time, as required by law. This may include changing, adding, or removing terms. We may do this in response to legal, business, competitive environment or other reasons not listed here.

Telehealth Consent

Telehealth is the type of care that allows clients to access health services using audio-video interface such as videoconferencing, as well as asynchronous communication methods such as patient-submitted questionnaires reviewed by licensed physicians.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits

  • Improved access to health care by enabling a client to receive services across distances and between programs.
  • More efficient health care including medical evaluation and management.
  • Obtaining expertise of a distant specialist.
  • Maintaining connections with established providers in other areas.

Possible Risks

As with any medical procedure, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

  • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician or other clinical staff.
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
  • In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

By Using Our Services, You Understand

  • That the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth which identifies you will be disclosed to researchers or other entities without your consent.
  • 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.
  • That you have the right to inspect all information obtained and documented in the course of a telehealth interaction and may receive copies of this information for a reasonable fee.
  • That a variety of alternative methods of health care may be available to you, and that you may choose one or more of these at any time.
  • That it is in your best interest to inform your physician or other clinical staff of any other healthcare providers involved in your medical care.
  • That you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.

Your continued use of the services constitutes your understanding and acceptance of the above terms and you hereby authorize the use of telehealth in the course of your diagnosis and treatment.

HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. This form is a summary version. A more complete text is available through our office. Additional information is available from the U.S. Department of Health and Human Services at www.hhs.gov.

Our Policies

  • Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, and health insurance payers as is necessary and appropriate for your care.
  • It is the policy of this office to remind patients of their appointments and treatment schedules. We may do this by telephone, e-mail, U.S. mail, or by any means convenient for the practice and/or as requested by you.
  • The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
  • You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
  • Your confidential information will not be used for the purposes of marketing or advertising of products, goods, or services.
  • We agree to provide patients with access to their records in accordance with state and federal laws.
  • We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient.
  • You have the right to request restrictions in the use of your protected health information and to request changes in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

Your continued use of the services constitutes your understanding and acceptance of the above terms set forth in the HIPAA Information Form and any subsequent changes in office policy. This consent shall remain in force from this time forward.

Financial Consent

I understand and accept the terms in order to render services that a credit card may be kept on file and that any remaining balances for services rendered shall be paid in full. I authorize pepti LLC to submit on my behalf and the release of any medical records or other information necessary to process my consultation order. Fee schedules and receipts for all professional services are available upon request.

I authorize pepti LLC to make invoice changes and debit my account for orders placed, goods received, and/or services rendered not fully covered by third party vouchers or credits.

I authorize pepti LLC to charge my credit card account upon any unpaid balances due.

All programs are auto-renewing and I consent to be automatically charged for any program I am a part of unless I explicitly request to cancel before my payment is processed. I certify that I am an authorized user of this credit card and that I will not dispute the payments with my credit card company. See our Refund Policy for approved exceptions.

Shipping Authorization

All prescription medications are dispensed according to state and federal law with the approval of the pharmacist in charge and in compliance with all laws applicable from the relevant Medical Boards and State Boards of Pharmacy. The customer requesting shipping disclaims and agrees to hold harmless pepti LLC for any delays or errors during the shipping process. Medication is considered dispensed and the order completed when it is signed out for shipping, not when it arrives via delivery.

Your continued use of the services constitutes your understanding and acceptance of the above terms and you give permission for pepti LLC to ship medication to you at the address provided in your intake form or any other address given by you to the company and agree to all of the conditions listed above.

Contact

For questions about this Medical Consent, contact us at legal@hellopepti.com.