Informed Consent Regarding Use of Telehealth
Last Updated: 12/31/2025
BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.
Service overview
This Informed Consent is for the undersigned’s (“you”, “I” or “your”) receipt of telehealth services (the “Services”) from VPMG P.C. and/or VPMG TX P.A. (collectively, “VPMG”) available through a technology platform offered by VPMG and its affiliates, including VPT Business Services, LLC and Viapromeds, Inc. (the “Platform”). The Services involve the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of providing and improving patient care. The Services may include diagnoses relating to men’s sexual health and wellness, remote prescribing, and health information sharing.
VPMG providers (our “Providers”) are an addition to, and not a replacement for, your primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not. Before you give your consent to request Services, please be aware of how receiving care through our Platform differs from an in-person visit with your primary care provider or other specialist for the same care. If you have any questions, please contact us.
Provider(s) will be interacting with you solely via use of the Platform. As a result, all of the medical care and treatment you receive from such Providers will be provided via telehealth, and you will not be able to meet with your Provider in a physical location. You will be provided with the name, credentials, licensure/certification, and qualifications of the Provider who will be providing your care. You may contact your Provider(s) for follow-up questions by sending a message to your Provider(s) via our Platform. Your Provider will respond at his or her earliest convenience. However, a Provider should not be contacted in the case of a medical emergency, as noted below.
For additional questions you may contact us via the Platform or via email at info@viapromeds.com.
Privacy and Security Considerations
The Platform will incorporate network and software security protocols designed to protect the confidentiality of your information and will include measures designed to safeguard the data and to ensure its integrity against intentional or unintentional corruption. However, if people are close to you during your appointment or while you are using the Platform, they may hear or see something you did not want them to know. You should be in a private place, so other people cannot hear you or see your screen while using the Platform. VPMG may send you email correspondence or other messages via that Platform that may contain details of your treatment. You understand that we do not and cannot guarantee the security or privacy of the services you use to receive communications, including for example your email service provider.
Expected Benefits
The use of telehealth may have the following possible benefits: improved access to care by enabling you to remain in your home while you receive Services; more efficient care evaluation and management; and access to the expertise of a specialist, as appropriate.
Possible Risks
While the use of telehealth in the delivery of care can provide potential benefits for you, there are also potential risks associated with the use of telehealth and other technology. These risks include, but may not be limited to the following:
Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating additional telehealth interactions or a meeting with your local primary care doctor.
The electronic nature of the Services means that there is a greater risk to the privacy of your electronic health information relative to visiting a health center.
In very rare events, security protocols could fail or technical failures may occur, causing a loss of data or information, or a breach of privacy of personal medical information.
The health information you provide may be the only source of health in formation used by the Provider(s) during the provision of Services, and such Provider(s) may not have access to additional medical records or information. In rare events, a lack of access to complete information or medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
The inability of your Provider(s) to conduct certain tests or assess vital signs in -person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency care.
Your Provider will NOT be familiar with or have access to available medical resources, including emergency resources, near your location. They will NOT be able to make a suitable local referral where medically indicated.
The Platform is not intended to be used for medical emergencies. In the case of a medical emergency, you should dial 9-1-1, go to your nearest urgent care center or emergency room, or contact your local emergency assistance services immediately.
By checking the box associated with “Informed Consent”, you acknowledge that you understand, agree with, and consent to the following:
I hereby consent to receiving VPMG’s Services via the Platform. I understand that VPMG and its Providers offer telehealth-based medical services, but that these services do not replace the existing relationship between me and my primary care doctor. I also understand it is up to the Provider(s) to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
I understand that Providers reserve the right to deny treatment if they believe that a patient may be better served by a local provider, or for any other reason according to their professional judgment.
I consent to VPMG providing copies of my medical records to my primary care physician for Services rendered through the Platform. I will provide VPMG with the name of my primary care physician through the Platform if and when I request that VPMG provide such copies of my medical records to my primary care physician.
I understand that VPMG P.C. and Providers operate subject to state regulation and may not be available in certain states.
I understand that VPMG is exclusively for the diagnosis and treatment of men’s sexual health and wellness (and related issues including, obesity), and not for any other medical conditions. I understand that Providers do not provide screening for cancer or for any other conditions aside from certain limited men’s sexual health and wellness conditions.
I certify that all of the information I will provide to Provider(s) will be true, accurate, and complete. I understand that if I knowingly provide false, misleading, or incomplete information to a medical professional, I may not be able to receive further Services. I further certify that I am who I say I am and that my profile information identifying me in the Platform is accurate and correct.
I understand I should ask questions about anything I do not understand by sending a message. I understand I must check the Platform regularly for messages in order to communicate with Providers, and that if I do not my care and treatment may be delayed.
I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
I understand that if I participate in a consultation, that I have the right to request a copy of my medical records by contacting us via the Platform, which will be provided to me at reasonable cost of preparation, shipping and delivery. I understand that there will be no recording of any online treatment sessions by my Provider(s) or me.
I understand that if I would like to have my records sent to my primary care provider, I must request such transfer of records by contacting us via the Platform, which will be transferred at reasonable cost of preparation, shipping and delivery.
I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that VPMG will take steps designed to make sure that my health information is protected. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state as well as with certain other third parties. This includes information provided with other individuals for communication, billing, and certain other business purposes. I understand, LLC and Viapromeds, Inc. obtaining, using, storing, and disseminating to necessary third parties, information about me and my image, as necessary to provide Services through the Platform.
I understand there is a risk of technical failures during the telehealth encounter beyond the control of VPMG I agree to hold harmless VPMG, and its affiliates, including VPT Business Services, LLC and Viapromeds, Inc. for delays in evaluation or for any loss of data or information due to such technical failures.
I understand I can also choose to fill my prescription at a pharmacy of my choice.
I understand that I will need to pay for Services received through the Platform myself and that VPMG does not accept any insurance or other third party payments. I further understand that any payments for Services may be processed through Viapromeds, Inc. since it operates the Platform and that Viapromeds, Inc. does not provide medical or health services. I understand that by using this Platform, I freely elect to pay out of pocket for all Services and prescriptions provided through the Platform and that I may be foregoing discounts or insurance coverage that would otherwise be available to me if I sought care in-person. I understand that it is my responsibility to arrange and pay for any follow-up care that VPMG recommends I receive. I further understand that VPMG does not cover the cost of any prescriptions.
I understand that there is no guarantee that I will receive a prescription.
I understand that VPMG’s Services are not an insurance product.
I understand that VPMG is not for emergencies. I understand that if I am experiencing a medical emergency, that I should dial 9-1-1 immediately and that the Providers are not able to connect me directly to any local emergency services.
If you would like to have your records sent to your primary care physician, please contact us at info@viapromeds.com.
Patient Consent: I have read this document carefully and understand the risks and benefits of the telehealth consultation and have had my questions regarding the Services explained. I hereby give my informed consent to participate in a telehealth consultation, and further permit Provider(s) to examine, consult, diagnose, or treat me under the terms described herein. I understand this informed consent will become a part of my medical record.
