INFORMED CONSENT FOR TELEMEDICINE SERVICES
Last updated: September 11, 2026
PROVIDER INFORMATION
DrWeight Online LLC
[INSERT FLORIDA BUSINESS OR MAILING ADDRESS]
Telephone: [INSERT TELEPHONE NUMBER]
Email: [INSERT EMAIL ADDRESS]
Website: [INSERT WEBSITE URL]
1. PURPOSE OF THIS CONSENT
This document explains the nature, potential benefits, limitations, and risks of receiving healthcare services through telemedicine.
By signing or electronically accepting this consent, I acknowledge that:
I have read and understand this document.
I have had an opportunity to ask questions.
I voluntarily agree to receive telemedicine services.
I may decline care through telemedicine.
This consent does not guarantee a prescription, treatment, or specific clinical outcome.
This consent supplements, but does not replace, the DrWeight Online Terms and Conditions, Privacy Policy, applicable Notice of Privacy Practices, medication- or treatment-specific consents, and instructions provided by the treating clinician.
2. WHAT IS TELEMEDICINE?
Telemedicine is the delivery of certain healthcare services when the patient and healthcare professional are in different locations and communicate using electronic technology. A telemedicine encounter may involve:
Live video or audio communication when clinically appropriate and legally permitted.
Electronic transmission of information.
A patient portal or secure messaging.
Exchange of documents, photographs, or test results.
During a telemedicine encounter, the clinician may obtain a medical history; assess symptoms; review medications, allergies, laboratory results, or diagnostic studies; observe visible findings; request patient-reported measurements; provide medical guidance; develop a diagnostic impression; recommend treatment; order testing; issue a prescription when medically appropriate; or recommend in-person care or evaluation by another professional.
3. DRWEIGHT ONLINE SERVICES
DrWeight Online primarily provides:
Medical weight-management services.
Metabolic-health evaluations.
Evaluation for pharmacologic treatment.
Follow-up for established patients.
Assessment of treatment response, tolerance, and side effects.
Review of progress and treatment goals.
Education regarding nutrition, physical activity, and health habits.
Other related medical services that may be offered.
DrWeight Online is not a substitute for my primary-care clinician and does not assume comprehensive management of all my medical conditions. I understand that I should maintain appropriate follow-up with my primary-care clinician and specialists.
4. ELIGIBILITY AND PATIENT LOCATION
I represent that:
I am at least twenty-one (21) years old.
I will be physically located in Florida at the time of each telemedicine encounter unless DrWeight Online confirms that the treating clinician is authorized to provide care in another jurisdiction.
I will provide my exact physical location at the beginning of the encounter when requested.
I will notify the clinician if my location changes during the encounter.
I have legal capacity to consent to healthcare.
The information I provide will be accurate, complete, and current.
I understand that the clinician may decline to begin or continue an encounter if my identity or location cannot be verified; I am outside a jurisdiction where the clinician may legally practice; available information is insufficient; telemedicine is not clinically appropriate; the connection prevents an adequate evaluation; or an emergency or condition requires in-person care.
5. IDENTITY VERIFICATION
At the beginning of an encounter, I may be asked to confirm my full name, date of birth, address, telephone number, current physical location, government-issued photo identification, emergency-contact information, or other information reasonably necessary to verify my identity.
I will not permit another person to use my account, link, or identity to receive healthcare services.
6. CLINICIAN IDENTITY
The clinician will identify themself at the beginning of the encounter and may explain their name, professional credentials, role in my care, and location when appropriate. I may ask questions regarding the clinician’s identity and credentials.
7. POTENTIAL BENEFITS
Potential benefits of telemedicine may include improved access to care, reduced travel and waiting time, the ability to receive care from a convenient location, easier follow-up, faster access to clinical guidance, continuity of treatment when an in-person visit is unnecessary, and electronic exchange of information or documents.
These benefits are not guaranteed and may vary according to my condition and circumstances.
8. LIMITATIONS OF TELEMEDICINE
I understand that a remote encounter has limitations, including:
The clinician cannot perform a complete hands-on physical examination.
Some clinical signs may not be visible or detectable remotely.
Audio or video quality may affect the evaluation.
Measurements I provide may be inaccurate.
Important information may be unavailable.
Some conditions require palpation, auscultation, testing, procedures, or an in-person examination.
An in-person evaluation may be required or repeated.
A diagnosis may be preliminary or limited.
Diagnosis or treatment may be delayed.
A prescription may be inappropriate without laboratory testing, records, vital signs, or an in-person examination.
The clinician may stop the telemedicine encounter and recommend in-person care at any time.
9. POTENTIAL RISKS
Potential risks include an incorrect, incomplete, or delayed diagnosis due to the limitations of remote evaluation; delayed in-person treatment; technology failures; internet, power, audio, or video interruptions; unauthorized access; accidental disclosure to nearby individuals; document-transmission errors; incomplete or inaccurate patient information; inaccurate home measurements; inability to respond physically to an emergency; and risks associated with medications prescribed after a limited remote examination.
No electronic communication system can guarantee absolute privacy or security.
10. PRIVACY AND CONFIDENTIALITY
Information generated during an encounter will be handled under applicable privacy laws and DrWeight Online policies. The clinician will make reasonable efforts to participate from a private location.
I agree to participate from a reasonably private place; avoid public or crowded areas; disclose whether another person is present; use headphones when appropriate; protect passwords, links, and devices; avoid sharing appointment links; use a secure internet connection when possible; and close applications or accounts after use.
If I participate from a vehicle, workplace, public location, or another place where others may hear, I accept the additional privacy risk. I will not drive during the encounter.
11. OTHER PERSONS PRESENT
When appropriate, the clinician will disclose whether another person is participating, such as clinical staff, trainees, interpreters, technical staff, caregivers, family members, or other professionals involved in my care.
I may ask who is present, request that a nonessential person leave, authorize a caregiver or family member to participate, or decline the participation of students or trainees when applicable. If I allow another person to remain with me, I authorize that person to hear health information discussed during the encounter.
12. RECORDINGS AND PHOTOGRAPHS
Telemedicine encounters are not routinely recorded. Neither party may record audio, video, or images of an encounter without the prior express consent of all participants, except as otherwise permitted by law.
Accepting this consent does not authorize recording. Any clinical recording requires separate authorization explaining its purpose, access, storage, retention, and withdrawal process when applicable.
13. CLINICAL PHOTOGRAPHS AND DOCUMENTS
I may be asked to submit laboratory results, medication lists, identification, clinical photographs, weight records, blood-pressure readings, medical records, or other information reasonably necessary for evaluation.
I authorize these materials to be used for evaluation, treatment, care coordination, healthcare operations, and legal compliance. I understand that ordinary email or text messaging may involve additional privacy risks. I will not send intimate or highly sensitive photographs through an unauthorized channel.
14. TECHNOLOGY PLATFORMS
Telemedicine and related processes may depend on third-party platforms for video communication, appointment scheduling, electronic medical records, forms, messaging, email, payment processing, pharmacies, electronic prescribing, and secure storage.
These providers may experience interruptions, technical failures, delays, compatibility problems, or security incidents. I authorize the Practice to use reasonably selected technology to facilitate my care.
If technology fails, the clinician may attempt to restore the connection, switch to another legally permitted method, continue through audio when clinically appropriate, reschedule the encounter, or recommend in-person care.
15. TECHNOLOGY-FAILURE PLAN
If the connection is interrupted, I authorize the clinician or staff to contact me at the telephone number I provided, and I will keep my telephone available during the encounter.
If communication cannot be restored, the encounter may be rescheduled; only the clinically safe portion may be completed; instructions may be provided through another authorized channel; or in-person care may be recommended. If I experience an emergency during an interruption, I will call 911 or go to the nearest emergency department.
16. EMERGENCIES DURING AN ENCOUNTER
DrWeight Online is not an emergency service. If the clinician reasonably believes that an emergency or serious threat to my health or safety exists, I authorize the clinician to instruct me to call 911; contact emergency services; contact my emergency contact; provide emergency personnel with my location and clinically necessary information; recommend transportation to an emergency department; or end the encounter to prioritize emergency care.
I authorize these actions when the clinician determines in good faith that they are reasonably necessary to protect my health or safety.
17. DO NOT USE TELEMEDICINE FOR EMERGENCIES
I will not use the website, patient forms, email, or text messages to request emergency care. For severe or potentially life-threatening symptoms, I will call 911 or immediately go to the nearest emergency department.
Emergency symptoms may include chest pain or pressure, difficulty breathing, fainting, sudden weakness, severe confusion, a serious allergic reaction, severe or persistent abdominal pain, persistent vomiting with inability to keep down liquids, significant bleeding, thoughts of harming myself or another person, or any condition I believe requires immediate attention.
18. EVALUATIONS AND PRESCRIPTIONS
I understand that participating in an encounter does not guarantee a prescription, specific medication or dose, dose increase, refill, laboratory order, letter, certificate, diagnosis, or treatment eligibility.
All clinical decisions remain subject to the clinician’s professional judgment. Before prescribing, the clinician may require laboratory results, medical records, vital signs, an in-person examination, consultation with my primary-care clinician, specialist evaluation, or additional follow-up.
I will not start, modify, increase, reduce, stop, or share medication without professional guidance.
19. WEIGHT-MANAGEMENT MEDICATIONS
I understand that medications used for weight management may cause adverse effects and complications. I will accurately disclose my medical conditions, prior surgeries, allergies, medications, supplements, history of pancreatitis, gastrointestinal problems, kidney or liver disease, gallbladder disease, pregnancy or breastfeeding status, possibility of pregnancy, personal or family history of medullary thyroid carcinoma, multiple endocrine neoplasia type 2, prior adverse effects, and weight treatments prescribed by other clinicians.
I understand that withholding information may result in serious complications.
20. PHARMACIES AND THIRD PARTIES
If a prescription is issued, I authorize the Practice to transmit necessary information to the appropriate pharmacy.
I understand that the pharmacy or external platform controls prescription acceptance, medication availability, price, payment processing, dispensing, shipment, delivery, and return or refund policies. DrWeight Online does not sell or deliver medication through its website. The consultation fee is separate from medication costs. A pharmacy may request additional information, decline a prescription, or lack inventory.
21. INFORMATION PROVIDED BY THE PATIENT
I will provide truthful, complete, and current information. I understand that the clinician relies on this information when making clinical decisions.
I will disclose all diagnoses, medications, supplements, allergies, recent hospitalizations, pregnancy or breastfeeding, treatment by other clinicians, adverse reactions, changes in my health, and relevant laboratory or diagnostic results.
False, incomplete, or misleading information may result in incorrect recommendations, drug interactions, adverse effects, delayed diagnosis, or suspension or termination of services.
22. PATIENT-PERFORMED MEASUREMENTS
I may be asked to report or measure weight, height, blood pressure, pulse, temperature, glucose, waist circumference, or other relevant values.
I understand that these measurements may be inaccurate because of faulty equipment, incorrect technique, estimates, outdated values, or transcription errors. I will make a reasonable effort to provide recent and accurate measurements. The clinician may require confirmation in person.
23. ALTERNATIVES TO TELEMEDICINE
Alternatives may include evaluation by my primary-care clinician, an in-person visit with another qualified healthcare professional, an urgent-care clinic, an emergency department, or declining the service.
I may ask whether an appropriate in-person alternative exists. The availability, cost, location, and waiting time for an alternative may differ.
24. RIGHT TO DECLINE
Telemedicine is voluntary. I may decline telemedicine before an encounter begins, and doing so does not affect my right to seek in-person care from another provider.
I will not be charged solely for declining telemedicine before the service is provided. This does not eliminate valid charges for other services already provided, purchased products, applicable late cancellations, or matters unrelated to my decision to decline telemedicine.
25. RIGHT TO WITHDRAW CONSENT
I may withdraw this consent at any time by verbal or written notice. Withdrawal will not affect the legality of services provided before withdrawal, remove information that must remain in the medical record, or waive valid charges. It may prevent an encounter from continuing through telemedicine and may require me to seek in-person care. Withdrawal applies prospectively after it is received.
26. RIGHT TO ASK QUESTIONS
I may ask questions before or during an encounter; request additional explanation; ask about risks, benefits, and in-person alternatives; ask who can access my information; request that the encounter stop; request that a nonessential person leave; and receive reasonable information regarding the treatment plan.
27. MEDICAL RECORD
I understand that the telemedicine encounter and clinically relevant communications may be documented in my medical record. The record may include this consent, medical history, symptoms, clinical observations, diagnoses, medications, prescriptions, results, documents, authorized photographs, treatment plans, and follow-up communications.
The record will be retained under applicable laws and Practice policies.
28. FOLLOW-UP COMMUNICATIONS
I authorize DrWeight Online to contact me regarding appointment confirmations, forms, results, instructions, prescriptions, refills, follow-up care, side effects, document requests, payments, and administrative matters.
Communications may occur by telephone, email, text message, patient portal, or appointment platform. These channels are not for emergencies, and messages may not be reviewed immediately. Message and data rates may apply.
29. PAYMENTS
DrWeight Online services are generally self-pay. I understand that the consultation fee is separate from medication costs; does not guarantee a prescription; does not include laboratory testing, diagnostic studies, pharmacy charges, or shipping; and is subject to the Practice’s payment, cancellation, and rescheduling policies.
A declined prescription, lack of treatment eligibility, or recommendation for in-person care does not necessarily mean that a completed medical evaluation lacked value or is not chargeable. I will not be charged solely for declining telemedicine before receiving the service.
30. NO GUARANTEE OF RESULTS
Medicine cannot guarantee outcomes. DrWeight Online does not guarantee a specific amount of weight loss, improvement within a specific period, medication tolerance, absence of adverse effects, medication availability, continued pricing, insurance approval or reimbursement, eligibility for an external program, or a prescription or refill.
Results depend on many individual factors.
31. PATIENT ACKNOWLEDGMENTS
By accepting this consent, I acknowledge that:
I have read this document or had it explained to me.
I understand the nature, potential benefits, risks, and limitations of telemedicine.
I had an opportunity to ask questions and received satisfactory answers.
I am at least twenty-one (21) years old.
I will be physically located in Florida during each encounter unless the Practice confirms that care may legally be provided from my location.
I will provide truthful and complete information.
I understand that telemedicine is not a substitute for emergency services.
I understand that a prescription is not guaranteed.
I understand that I may need an in-person evaluation.
I understand that I may withdraw my consent.
I voluntarily agree to receive healthcare through telemedicine.
32. AUTHORIZATION
By handwritten signature, electronic signature, selection of an acceptance checkbox, or documented verbal confirmation when legally permitted:
I VOLUNTARILY AUTHORIZE DRWEIGHT ONLINE LLC AND ITS AUTHORIZED HEALTHCARE PROFESSIONALS TO PROVIDE HEALTHCARE SERVICES TO ME THROUGH TELEMEDICINE.