Last updated: October 23, 2026

Telehealth Informed Consent

Elite Care Health, for patients accessing care through DemaFora Health

Effective date: [EFFECTIVE DATE]

Please read this consent carefully before starting care. You will be asked to agree to it during intake.

1. Who provides your care

Your care is provided by independent, licensed clinicians (physicians, nurse practitioners, or physician assistants) in Elite Care Health ("Providers"). DemaFora Health is a membership brand and does not practice medicine. The intake technology is operated by Karpa Health. Prescriptions, if any, are filled by Rx Ave.

2. What telehealth is

Telehealth means receiving health care remotely using technology instead of an in-person visit. Your care may include:

• Online medical questionnaires and intake forms
• Secure messaging with a Provider
• Video or phone visits, where required by your state or your Provider
• Review of lab results, photos, or other information you share
• Electronic prescriptions sent to a pharmacy

Your Provider may be located in a different place than you but will be licensed in the state where you are located at the time of care.

3. Possible benefits

• More convenient access to care without traveling
• Faster communication with a Provider
• Care from home, at times that work for you

4. Possible risks and limitations

• No physical exam. A Provider cannot examine you in person, which may limit what they can assess. Your Provider may require labs, a video visit, or an in-person evaluation before treating you.
• Information you provide matters. Decisions depend on accurate and complete information. Missing or inaccurate information could lead to errors, including harmful drug interactions or side effects.
• Technology problems. Poor connections, file quality, or system failures could delay or interrupt care.
• Security. Despite reasonable safeguards, electronic communications carry a risk of unauthorized access.
• Not everything can be treated remotely. Your Provider may decide telehealth is not appropriate for you and refer you to in-person care.
• Medication risks. All medications, including GLP-1 medications, can have side effects and risks. Your Provider will discuss these with you, and you should read the medication information provided by the pharmacy.

5. Not for emergencies

Telehealth through this service is not for emergencies or urgent care. If you are experiencing a medical emergency, call 911 or go to the nearest emergency room immediately. Messages to your care team may not be answered right away. If you are having thoughts of harming yourself, call or text 988 (Suicide & Crisis Lifeline).

6. Your responsibilities

• Provide truthful, complete, and current health information
• Tell your Provider about all medications, supplements, allergies, and conditions
• Follow your Provider's instructions and complete requested labs or follow-up
• Report side effects or changes in your health promptly
• Maintain a relationship with a primary care provider for your overall care [COUNSEL: confirm whether to require or recommend]
• Be located in a state where services are offered at the time of each visit

7. Prescriptions

Any prescription is at the sole discretion of your Provider based on their clinical judgment. Signing up or paying for a membership does not guarantee a prescription. A valid prescription is required for all prescription medications. Some medications are subject to additional federal and state rules, which may require an in-person or video evaluation. [COUNSEL: confirm DEA/Ryan Haight telemedicine requirements and current flexibilities for controlled substances.]

8. Privacy

Your health information is protected under federal and state law, including HIPAA. It will be used and shared as described in the Elite Care Health Notice of Privacy Practices at [LINK]. Your information may be accessed by your Providers, Karpa Health as a technology service provider, Rx Ave, and labs as needed for your care.

9. Your rights

• You may refuse or stop telehealth care at any time without affecting your right to future care, and you may request in-person care elsewhere.
• You may ask questions about your treatment, its risks, and alternatives.
• You may request copies of your medical records.
• You may withdraw this consent at any time by contacting [PROVIDER GROUP CONTACT] or [SUPPORT EMAIL]. Withdrawal does not affect care already provided.

10. State-specific provisions

[STATE-SPECIFIC CONSENT LANGUAGE — insert any additional disclosures or consent requirements for each state where services are offered, e.g., verbal consent documentation, video visit requirements, provider identity/licensure disclosure, or complaint contact information for state medical boards.]

11. Consent

By checking the box or signing below, I confirm that:

• I am at least 18 years old and located in a state where services are offered;
• I have read and understand this Telehealth Informed Consent;
• I have had the opportunity to ask questions; and
• I consent to receive health care services via telehealth from Elite Care Health.

Name: ______________________ Date: ____________ [OR ELECTRONIC ACCEPTANCE]