Telehealth Consent Form

Telehealth involves delivering care using secure electronic communications, including:

• online medical questionnaires
• secure messaging
• audio or video calls
• digital transmission of medical information, images, and records

This allows licensed clinicians to evaluate, diagnose, and treat you without an in-person visit.

Telehealth is not appropriate for emergencies.

Care is provided by independent, U.S licensed clinicians who work with L'vae through a regulated telehealth provider network. These clinicians:

• review your consultation
• determine if treatment is safe and appropriate
• issue prescriptions when clinically necessary
• monitor your ongoing care when applicable

Prescriptions are filled by our licensed pharmacy partner.

L'vae itself does not provide medical treatment and does not employ the clinicians who care for you.

By consenting to telehealth, you acknowledge that it has limitations, including:

• clinicians may be unable to perform a physical examination
• some conditions may require in-person assessment
• delays may occur in the event of technical issues
• telehealth is not suitable for all medical concerns
• the clinician may decide you are not a candidate for treatment

You agree to seek immediate in-person care if advised by the clinician or if your symptoms worsen.

To ensure safe care, you agree to:

• provide complete, accurate, and truthful information
• disclose your full medical history, current medications, and allergies
• use the medication only as prescribed
• promptly report any side effects or changes in health
• keep your information up to date
• inform your primary care provider of any treatment you receive through L'vae

Providing false or incomplete information may lead to harm and may result in denial of care.

You understand that:

• communication may occur asynchronously
• response times are not immediate
• telehealth clinicians will provide instructions for follow-up when needed
• you may contact support if you have questions about your treatment

Telehealth communications are recorded in your secure medical record.

You acknowledge that:

• controlled substances will not be prescribed
• prescriptions are provided only when medically appropriate
• your clinician may refuse or discontinue treatment if unsafe
• prescriptions are dispensed exclusively by our licensed pharmacy partner
• prescriptions must not be shared with others

Telehealth prescribing follows all federal and state laws.

Your personal and medical information is protected in accordance with:

• the L'vae Privacy Policy
• federal and applicable state privacy laws
• secure technical and organizational safeguards

Electronic communications are encrypted, but no method is guaranteed 100% secure.

You may review the full Privacy Policy at any time on our website.

You understand that:

• L'vae services are cash-pay only
• we do not accept or process insurance
• subscription charges, telehealth fees, and medication costs will be clearly disclosed before purchase
• you are financially responsible for all charges incurred through your account

By agreeing to this Telehealth Consent, you confirm that:

• you understand the risks, benefits, and alternatives to telehealth
• you voluntarily consent to receive telehealth medical services
• you may withdraw consent at any time (but this may affect your ability to receive care)
• you understand that declining or withdrawing consent will not affect your ability to use non-clinical features of the website

You may withdraw consent by contacting customercare@lihv.com.

You consent to the use of electronic signatures and electronic medical records.

You agree that your actions such as clicking "Submit," "Agree," or "Continue" constitute your legal consent.

If you have questions about this Consent or your telehealth care, contact: