Telehealth Consent Form

Effective Date: January 1, 2026

This document constitutes your informed consent to receive telehealth services from MyTelePep, located at 4800 N. Federal Hwy., Suite 105B, Boca Raton, FL 33431. You must read, understand, and acknowledge all items below before your consultation can proceed. Required by Florida law (F.S. §456.47).

What Is Telehealth?

Telehealth is the delivery of healthcare services using audio-visual communication technology that allows a patient and provider to interact in real time from separate locations. At MyTelePep, all consultations are conducted via HIPAA-compliant two-way live video. MyTelePep is a telehealth-only provider and does not offer in-person care.

Benefits of Telehealth

Convenient access to licensed Florida providers from your home or any private location in Florida
Elimination of travel and waiting room time
All-inclusive program pricing — medication, visits, and shipping bundled into one monthly fee
Secure electronic prescriptions sent directly to licensed compounding pharmacies

Limitations of Telehealth

You should be aware that telehealth has inherent limitations:

Providers cannot perform a physical examination via telehealth
Technology failures (internet outages, audio/video issues) may disrupt your visit
Electronic transmission of health information carries some risk of interception, though MyTelePep uses HIPAA-compliant encrypted platforms to minimize this risk
Your provider may determine that additional diagnostic information is needed before prescribing

Your Provider's Identity and Credentials

Under Florida Statute §456.47, you have the right to know the identity and credentials of your provider before and during your visit. At the start of every consultation, your provider will disclose their full name, license type (MD, PA, or APRN), and Florida license number. You may verify any Florida provider's license at flhealthsource.gov.

Florida Residency Requirement

You must be physically located in Florida at the time of your consultation. MyTelePep is licensed to provide care only to patients in Florida. Your provider will confirm your identity and physical location at the start of every visit. If you are not in Florida, the visit cannot proceed.

All-Inclusive Program Pricing

Your monthly program fee is all-inclusive — it covers physician consultation, compounded medication, and shipping
There are no separate pharmacy invoices or per-visit fees
You may cancel your program at any time with no cancellation fee
A specific prescription or compound is not guaranteed — your provider exercises independent clinical judgment
If physician approval cannot be obtained after your initial evaluation, your first month's fee will be refunded in full

Compounded Medications Disclosure

If your provider prescribes compounded peptides, you acknowledge:

Compounded peptides are not FDA-approved drugs
They have not been evaluated by the FDA for safety, efficacy, or therapeutic equivalence
They are prepared by a licensed 503A compounding pharmacy under your physician's prescription
Results vary and are not guaranteed
You may decline any prescribed compound at any time without penalty

Privacy and HIPAA

All telehealth sessions are conducted on a HIPAA-compliant, encrypted video platform. Your health information is protected under HIPAA and our Notice of Privacy Practices. Please conduct your consultation from a private location to protect your own privacy.

Patient Acknowledgment

Please click each item to confirm your understanding before signing.

I am 18 years of age or older

I am a Florida resident and will be physically located in Florida at the time of my consultation

I understand that MyTelePep is a telehealth-only provider and does not offer in-person care

I understand that telehealth consultations do not include a physical examination

I have been informed of my right to know my provider's name, license type, and Florida license number, disclosed at the start of every visit

I understand my health information is protected under HIPAA and I have been offered a copy of the Notice of Privacy Practices

I understand my monthly program fee is all-inclusive — it covers physician consultation, medication, and shipping with no separate pharmacy bills

I understand I may cancel my program at any time with no cancellation fee

I understand that a specific prescription or compound is not guaranteed — my provider exercises independent clinical judgment

I understand that any compounded peptides prescribed are not FDA-approved drugs and have not been evaluated by the FDA for safety or efficacy

I may decline or discontinue any prescribed compound at any time without penalty

I have read and agree to the Terms of Service, Privacy Policy, and this Telehealth Consent Form

Patient Signature

Full Legal Name

Date of Birth

Email Address

Date Signed

Electronic Signature (Draw Below)

Sign HereClear Signature

Typed Full Name Confirmation

✓ Your consent has been recorded. A copy will be sent to your email address and added to your patient record. You may now proceed with your program enrollment.

Telehealth Informed Consent