By checking the box, you agree to receive medical services via telehealth (remote consultations using digital technologies). You understand:

• Your evaluation will be reviewed by a licensed healthcare provider remotely.

• No in-person physical exam will be performed.

• Telehealth may have limitations in diagnosis and treatment.

• You can ask questions at any time by contacting Affinity.

• I understand that if my condition worsens, does not improve or if I have worries about my treatment, I should see a healthcare provider in person.

This consent is valid for today’s visit and any future care provided by Affinity Whole Health via telehealth.

Telehealth is not for medical emergencies. In case of a medical emergency, dial 911 or go to the nearest emergency room. 

You authorize Affinity Whole Health and its affiliated providers to:

• Review your medical history and evaluation responses.

• Prescribe medications if appropriate.

• Arrange any necessary diagnostic testing or referrals.

You understand:

• All information you provide must be truthful and accurate.

• You should consult your primary care physician before beginning treatment.

• You may stop treatment at any time by contacting Affinity.

• You will follow the instructions, treatment and dosage schedules prescribed by Affinity providers. 

• You will immediately cease any medical treatment prescribed by Affinity in the event of adverse reaction or side effects and inform Affinity at info@affinitywholehealth.com. 

• Affinity does not direct, control or influence the medical treatment decision made by Affinity affiliated licensed providers which may include physicians, nurse practitioners and physician assistants.  

We respect your privacy. Here’s how your health information is protected and used:

Your Rights:

• Request a copy of your medical records.

• Ask us to correct errors in your records.

• Choose how we communicate with you (email, phone, etc.).

• Limit what we share and request a list of disclosures.

• Choose someone to act for you. 

• File a complaint if you feel your right are violated: Directly to us, U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. 

How We Use Your Info:

• To treat you and manage your care

• For billing and administrative purposes

• As required by law (e.g., public health, legal requests)

Access: You can view your medical records through our secure patient portal at any time or by requesting a copy.

By continuing, you agree to receive communication from Affinity via email and/or SMS for purposes such as:

• Prescription updates

• Appointment reminders

• Lab results or medical guidance

• Billing or service notifications

You understand:

• These messages are not encrypted and may be visible if intercepted.

• You can opt out at any time by emailing info@affinitywholehealth.com.

Scope of Services:

• Affinity provides telehealth consultations, medical management, and coordination of treatment.

• Providers may be licensed in a different state from your residence.

Payment:

• You agree to pay for treatment based on the plan you select.

• Services are not covered by insurance or Medicare.

Limitations:

• Affinity is not responsible for the actions of third-party labs, pharmacies, or service providers.

• This service is not intended for emergency care.