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Telehealth Informed Consent

Version 3

Service availability: UpLiftRX is not currently accepting patient intake or medication orders. This document remains available for reference and does not indicate that clinical, pharmacy, laboratory, or fulfillment services are active.

Effective August 8, 2026 · Version 3

IF YOU ARE HAVING A MEDICAL EMERGENCY OR A MENTAL HEALTH CRISIS, CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM. TELEHEALTH IS NOT FOR EMERGENCIES.

Please read this consent carefully before your visit. By signing it, you agree to receive care by telehealth from a licensed clinician affiliated with UpLiftRx (your "Provider").

What telehealth is

Telehealth is the delivery of healthcare using electronic communication between you and a Provider who is not in the same physical location as you. Depending on your program and your state, your visit may take place by secure video, by telephone, or by a store-and-forward review in which your Provider evaluates the intake, photographs, and records you submit and responds through the portal. Telehealth may involve:

  • electronic transmission of your medical history, photographs, and other health information to your Provider;
  • live or asynchronous interaction between you and your Provider by video, audio, or secure messaging;
  • transmission of prescriptions to a pharmacy and orders and results to and from a laboratory; and
  • review of data from at-home tests or connected devices.

Possible benefits

  • Access to a licensed clinician without travel or time away from work
  • Faster evaluation and, when appropriate, treatment
  • Continuity of care through ongoing secure messaging with your care team
  • Medical records that are available to you in your portal at any time

Possible risks and limitations

You should understand that telehealth is not the same as an in-person visit and carries risks, including:

  • Your Provider cannot perform a hands-on physical examination, which means information important to your diagnosis may be unavailable.
  • The information transmitted may be insufficient or of poor quality — for example, a photograph that is blurry or poorly lit — which could affect your Provider's assessment.
  • Technical failure, connectivity problems, or equipment malfunction may delay or interrupt your visit, evaluation, or treatment.
  • Rarely, despite encryption and other safeguards, electronic transmission could be intercepted or a security breach could occur.
  • Delays in evaluation or treatment can occur for reasons outside anyone's control.
  • Your condition may require an in-person examination, testing, procedure, or referral to a specialist, in which case your Provider will tell you and you will need to seek in-person care.
  • Not all treatments are available in every state, and regulatory requirements may limit what your Provider can prescribe.

Your responsibilities

You agree that you will:

  • provide complete, honest, and accurate information about your identity, age, location, medical history, allergies, current medications, supplements, and symptoms — withholding or misstating information can lead to serious harm, including a dangerous drug interaction;
  • be physically located in a state where your Provider is licensed at the time of your visit;
  • follow the treatment plan, dosing, monitoring, and follow-up instructions you receive, and complete any laboratory testing your Provider orders;
  • promptly report side effects, adverse reactions, or changes in your health to your care team, and seek emergency care when warranted;
  • keep an ongoing relationship with a primary care physician — telehealth through UpLiftRx addresses a specific concern and is not comprehensive primary care; and
  • keep your account credentials confidential and use a private, secure connection for your visit.

No guarantee of outcome or of treatment

Your Provider exercises independent professional judgment. No specific result, diagnosis, prescription, or outcome is guaranteed. Your Provider may determine, in their sole discretion, that your condition is not appropriate for treatment by telehealth or that a particular medication is not appropriate for you. Care may be discontinued at any time in your Provider's clinical judgment.

Privacy of your information

Information collected during your care is protected health information and is used and disclosed as described in our Notice of Privacy Practices. Visits are conducted on encrypted platforms. Visits are not recorded unless you are told in advance and give separate consent; you may decline recording, and declining will not affect your care. You may request that a copy of your telehealth records be sent to another provider by messaging your care team.

Alternatives

You have the right to receive care in person instead of by telehealth. If you prefer an in-person evaluation, do not proceed; your Provider or care team can tell you what UpLiftRx cannot address remotely.

Withdrawing consent

You may withdraw this consent at any time, for any reason, by messaging your care team or emailing support@upliftrx.co. Withdrawal applies going forward and does not affect care already provided. If you do not withdraw it, this consent renews with each subsequent consultation.

Technical failures

You agree to hold UpLiftRx and its affiliates harmless for loss of information or delays in care caused by technical failures outside of our reasonable control, to the extent permitted by law. This does not limit your Provider's professional responsibility for the care they provide.

Acknowledgment

By signing below, you confirm that: you have read and understood this consent; you have had the opportunity to ask questions and your questions have been answered; you understand the benefits, risks, and limitations of telehealth and the alternative of in-person care; you understand that you may withdraw consent at any time; and you consent to receive care by telehealth from your UpLiftRx-affiliated Provider.

Notice to patients — Open Payments database

For informational purposes only: the federal Physician Payments Sunshine Act requires that information about payments and other transfers of value over ten dollars ($10) from drug, device, and biologic manufacturers to physicians and teaching hospitals be made public. You may search this federal database at openpaymentsdata.cms.gov.