Telehealth Consent


Last modified: April, 2024

Hello, and welcome to Wellnus! Wellnus is a primary care clinic that offers culture-centerd, exceptional primary care services directly via telehealth.

This telehealth consent agreement explains the benefits and certain limitations of using virtual visits to receive medical care. As a courtesy, we want to call your attention to several parts of it. You should know though that these highlights are not part of our official, binding legal terms. The official legal terms follow under the “Informed Consent” heading below.

Remote digital healthcare allows you to receive health care service in the convenience of your home, get timely and efficient appointments, and can help you better navigate the health system. However, there are also potential limitations like, in rare cases, your doctor could find the information you transmitted is insufficient to make a medical decision, meaning you will have to go in-person to a doctor, or that despite our strong security measures, your information could be breached by a bad actor.

The Medical Group that you (or your child, if applicable) will be connected to through Wellnus uses a team-based approach. All care teams consist of multiple licensed physicians and other healthcare professionals, and in any given encounter you may interact with multiple healthcare professionals. This allows you (or your child, if applicable) to get better care faster.

By using the Wellnus service, you authorize Wellnus to bill you directly for the digital healthcare services as a private patient. No copays or insurance required.
You have a right to refuse to participate in services delivered via telehealth. 

Last modified: April, 2024

Informed Consent
Telehealth involves the use of electronic communications to enable healthcare providers at different locations than their patients to share individual patient medical information for the purpose of improving patient care. Such electronic communications may involve asynchronous or synchronous text-based, live audio-visual, and/or audio-only communications. Telehealth services offered by The Wellness Clinic Inc., and its related practices (collectively “Wellnus”) may include medical history review, evaluation and assessment, physical or virtual examination, record review, diagnosis, remote prescribing, provision of a treatment plan, health information sharing, therapy, follow-up, referrals, and patient education. The information you provide may be used for any of the aforementioned services, and may include any combination of the following: (1) health records and test results; (2) interactive asynchronous or synchronous chat communications; (3) live two-way communications; and/or (4) images. The electronic communication systems we use through an independent platform, specifically Charm Health, already incorporate network and software security protocols to protect the confidentiality of patient data and include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Wellnus will not be held liable for the security provisions of the independent platform Charm Health. 
Wellnus uses a team-based approach, with care teams consisting of multiple licensed physicians and other healthcare professionals. In any given encounter you may interact with multiple healthcare professionals, which allows you to get better care faster.

You should be aware that there are both benefits and risks associated with telehealth. Remote digital healthcare allows you to receive timely and efficient health care service in the convenience of your home and can help you better navigate the health system. However, there are also potential limitations. For example, your provider might need more complete medical records to optimize their decision-making or provide treatment, and they may need to refer you to an in-person doctor. Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies. Or, despite our strong privacy and security measures, your information could be improperly accessed or used by a bad actor. You understand that no results can be guaranteed or assured.
In the event of an inability to communicate as a result of a technological or equipment failure, please contact Wellnus by email at If you are experiencing an emergency, please call 911 for immediate access to emergency services. Wellnus providers are not able to connect you directly to any local emergency services.

All Telehealth Services
By clicking to accept this consent, you attest that you are at least 18 years of age and have legal authority to agree to this consent on behalf of yourself if you are the patient, or on behalf of your minor child if you are the parent/guardian of the patient, and you acknowledge and agree to the following:

I hereby consent to Wellnus providing its services via telehealth technologies. I understand that the risks and benefits of any particular treatment will be identified at the time of care plan provision, that recommended care plans can be access through your patient folder, and that if I do not consent to proceed with a particular care plan, I should share my specific concerns with my provider so that they may discuss them with me and consider an alternative care plan if medically appropriate. I understand that Wellnus and its providers offer telehealth-based medical services, but that these services are not intended to constitute a primary care provider relationship if I (or my child, as applicable) have not designated, or been assigned to, Wellnus as my (or my child’s, as applicable) primary care provider. I also understand Wellnus’s providers will determine whether or not my (or my child’s, if applicable) specific clinical needs are appropriate for a telehealth encounter, and I understand that Wellnus is not intended to replace my in-person provider(s) for services which a Wellnus provider determines are not appropriate for a telehealth encounter.

If I would like to speak to a different provider than the one involved in my encounter, I have the right to select another provider, although there could be a delay in service. If I would like to see an in-person provider, I will need to find my own services that are separate to Wellnus.

I understand that it is my responsibility to keep my physical address updated to ensure it reflects the state in which I am physically located, as well as the state in which my preferred pharmacy is located, whenever consulting with a Wellnus provider.

I understand the importance of Wellnus’s providers having accurate medical history and current medication information, and will keep my health profile updated. I understand that there is no guarantee that any prescription for any medication will be ordered, and that Wellnus does not prescribe controlled substances (e.g., narcotics for pain).

I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Wellnus’s Notice of Privacy Practices describes how Wellnus protects, uses and discloses medical information and how I can get access to this information. I understand that my healthcare information may be shared with other individuals for treatment, payment, or healthcare operations purposes, and that persons may be present during the consultation other than my provider in order to operate the telehealth technologies. I have a right to ask for the identities of parties present during the consultation.
I understand that I have the opportunity to provide my PCP’s information through the Charm Health platform. If I do so, I consent to Wellnus sharing all my medical records with my PCP, including any sensitive records related to mental health, reproductive health, substance use, HIV, and STDs/STIs.

I understand that the information Wellnus may share with my health plan for treatment, payment, or healthcare operations purposes may include sensitive records related to mental health, reproductive health, substance use, HIV, and STDs/STIs, and I specifically consent to such information being shared.

I understand and agree that I am financially responsible for payment of all charges incurred. All services provided by Wellnus Co. are paid for directly by you (the patient) and will not be paid by insurance or health care benefits. This includes any and all products (e.g. subscriptions and medications) provided or services rendered to me. Wellnus reserves the right to refuse to provide services on accounts that are delinquent.

I understand there is a risk of technical failures during the telehealth encounter beyond the control of Wellnus. I agree to hold harmless the Medical Group for delays in evaluation or for information lost due to such technical failures.
I understand that I have the right to withhold or withdraw this consent to the use of telehealth at any time, and I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that alternatives to telehealth consultation, such as in-person services, are available (not through Wellnus).

I understand that if I am agreeing to this consent as a parent/guardian on behalf of my child, I am consenting to Wellnus’s provision to my child of any services which Wellnus deems appropriate to be provided to my child via telehealth, except for services which my child confidentially consents to, on their own behalf, to the extent permitted by applicable state law. I further understand that the Children’s Online Privacy Protection Act (COPPA) requires parental or legal guardian consent for the online collection, use, and disclosure of personal information of children under 13 years of age, and I hereby authorize Wellnus to collect personal information about my child when my child uses Wellnus’s online services, including to access care via video visits or secure messaging. I have reviewed the COPPA statement incorporated into Wellnus’s Privacy Policy, and by providing this consent, I attest that I am the parent or legal guardian of the registered child. I understand and consent to the collection, use and/or disclosure of my child’s personal information as described in Wellnus’s Privacy Policy. I may revoke my consent at any time by contacting, but if I revoke my consent while my child is under 13 years of age, my child may not continue to access or use Wellnus’s online services.

I understand that I have the right to request a copy of any medical records Medical Group has regarding any services provided to me (or my child, if applicable). Requested medical records will be provided to at reasonable cost of preparation, shipping and delivery.

I understand that Wellnus is affiliated with any third-party sources of information, and therefore Wellnus makes no promise that third-party sources will be accurate or fault free. Further, I understand that Wellnus is not responsible for the accuracy of health records or health data that are created by any third-party sources.