About This Consent
Thank you for choosing Ironvale RX, Bask Health Inc (“Bask”), and Arora Health & Aesthetics, LLC or another independent professional entity providing your care through the platform (each, the “Medical Group”). You are viewing this form because you have elected to receive telehealth services from a Medical Group clinician via the Bask platform in connection with a GLP-1 weight-management program. Your clinician is a licensed healthcare practitioner — a physician, nurse practitioner, or physician associate, as permitted by the law of your state — licensed in the state where you are located.
BY CLICKING “I AGREE,” I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE TERMS PRESENTED BELOW, THAT I UNDERSTAND THE RISKS AND BENEFITS OF TELEHEALTH (INCLUDING ASYNCHRONOUS TELEHEALTH), AND I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN TELEHEALTH UNDER THESE TERMS.
Contents
What Is Telehealth?
Telehealth (or telemedicine) is the delivery of healthcare services — including examination, consultation, diagnosis, and treatment — through electronic communication technologies when you are in a different location than your healthcare practitioner. Telehealth allows you to receive treatment without traveling to another location and helps you avoid the wait times of an in-person visit.
Asynchronous and Synchronous Visits
Asynchronous (“store-and-forward”) telehealth means you and your clinician exchange information at different times — for example, secure intake questionnaires, photos, and text-based messaging (SMS/MMS). Synchronous telehealth means a real-time interaction with your clinician by audio-video or, where permitted, audio-only communication. The platform supports both: (1) text-based clinician-patient interactions and secure store-and-forward questionnaires; and (2) scheduled real-time audio-video visits.
Which modality is used is determined by your clinician in accordance with applicable law and clinical judgment. Some services, conditions, or states require a real-time audio-video visit (or, in some cases, an in-person examination) before treatment may be provided. You agree to complete a synchronous visit when your state or your clinician requires one. Asynchronous care will not be used where the law or your clinician requires a synchronous or in-person evaluation.
Possible Risks of Telehealth
As with any medical care, telehealth carries potential risks. The Medical Group believes the likelihood of these risks is very low. They include, without limitation:
- Delays in evaluation or treatment due to equipment or internet deficiencies or failures, including poor data quality or outages. You may reschedule a visit if interruptions occur.
- Failure of security protocols, causing a breach of privacy of personal medical information.
- Because the Medical Group does not have access to your complete medical records, failing to disclose your full medical history — diagnoses, treatments, medications and supplements, and allergies — may result in adverse drug interactions, allergic reactions, or other negative outcomes.
- Telehealth services are NOT emergency services and your information WILL NOT BE MONITORED 24/7. IF YOU THINK YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.
THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE HEALTHCARE PRACTITIONER TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE PRACTITIONER WILL DETERMINE WHETHER THE CONDITION BEING DIAGNOSED OR TREATED IS APPROPRIATE FOR A TELEHEALTH ENCOUNTER, AND WHICH TELEHEALTH MODALITY IS APPROPRIATE.
Your Rights and Acknowledgements
- You have the same privacy rights via telehealth that you would have during an in-person visit. Identifiable images or information from your telehealth visit will not be disseminated to researchers or other entities without your written consent. For more information, please read the Medical Group’s Notice of Privacy Practices.
- Telehealth may involve electronic communication of your personal medical information to healthcare practitioners located in other areas, including out of state.
- You may expect the anticipated benefits of telehealth, but no results can be guaranteed or assured.
- All information you submit via the platform, and all information your clinician enters, becomes part of your medical record, which is available to you by emailing contactus@arorahealthgroup.com and is subject to the same restrictions on dissemination without your consent.
- Your clinician’s initial message to you will include their name and credentials, and this will be recorded as part of your medical record.
- You may withdraw your consent to telehealth and request deletion of your patient profile at any time by emailing contactus@arorahealthgroup.com. Withdrawal will not affect care already provided, and record-retention laws may require the Medical Group to retain your medical record.
- Your healthcare information may be shared in accordance with the Notice of Privacy Practices and the laws of the state in which you are located, including:
- When a valid court order is issued for medical records.
- To report suspected abuse, neglect, or domestic violence.
- To prevent or reduce a serious threat to anyone’s health or safety.
- Some states require additional telehealth disclosures or verbal/written consent elements; where your state requires them, they will be presented to you and are incorporated into this consent.
Where your information is collected and stored: your intake responses and consents are collected and stored on the secure Bask platform, and your medical records are created and maintained by the Medical Group. The Ironvale RX landing pages do not store your health information.
Call, Email, and Text Messaging Consent
You expressly consent to allow the Medical Group, its healthcare practitioners, and platform representatives acting on their behalf to call, email, or text you (via SMS/MMS) regarding your personal data, appointments, or similar matters related to your telehealth encounters using the contact information you provide. Calls or texts may be placed using an auto-dialer or a pre-recorded or artificial voice, even if your number is on a do-not-call list. Your carrier’s normal rates may apply. THIS CONSENT IS NOT A CONDITION OF PURCHASE. You may revoke this consent at any time by emailing contactus@arorahealthgroup.com or by replying STOP to any text message.
This Telehealth Informed Consent is valid for the duration of your treatment with the Medical Group, including any affiliated or successor professional entity that assumes responsibility for your care.