By agreeing below, you confirm that you understand and consent to receive health care from Male Medical Group by telehealth (secure two-way audio-video) in addition to in-person visits.
- What telehealth is. Your provider evaluates you using live video and electronic health information instead of, or in addition to, an in-person visit. Visits take place on Doxy.me, a HIPAA-compliant video platform. No account or app download is required. Visits are not recorded.
- Texas only. You must be physically located in Texas during every visit. We verify your identity and Texas residence/location with a valid driver’s license or Texas ID card before any prescription is issued. We do not provide services, issue prescriptions, or ship medication to patients outside Texas.
- Exam and labs are required first. Before any prescription, you must complete a physical examination and laboratory testing appropriate to your condition. Your provider decides whether treatment is appropriate after reviewing your history, exam and results. A video visit does not guarantee a prescription.
- Video visit. Where applicable, your provider evaluates you by a HIPAA-compliant Doxy.me video visit before prescribing, in addition to the required physical exam and laboratory testing.
- Controlled substances. Some medicines we prescribe may be controlled substances. Federal and Texas rules apply to prescribing them by telehealth.
- Benefits and risks. Telehealth can make care more convenient. Risks include: technology failure or poor connection that interrupts the visit; limits of a video exam compared with an in-person exam, which may lead to missed findings or a need for an in-person visit; and, despite safeguards, the possibility of unauthorized access to electronic information.
- Not for emergencies. Telehealth is not for emergencies. If you have chest pain, trouble breathing, an erection lasting more than 4 hours, thoughts of harming yourself, or any other emergency, call 911.
- Compounded medication. Some medications we prescribe are compounded by licensed pharmacies. Compounded medications are not FDA-approved. The testosterone used in our testosterone replacement therapy is compounded. Compounded medications are prescribed only after laboratory testing, a physical exam and a provider evaluation. See our Compounded Medication Disclosure.
- Privacy. We protect your information as described in our Notice of Privacy Practices and Privacy Policy. You agree not to record visits without permission.
- Your rights. You may decline telehealth at any time and ask for an in-person visit; this will not affect your right to future care. You may withdraw this consent in writing. You may file a complaint about your care with the Texas Medical Board (www.tmb.state.tx.us).
- Follow-up and records. Your provider will tell you how follow-up works. To reach us, call (210) 263-9878 during office hours (Tuesday–Friday 8:00am–5:00pm, Saturday 9:00am–12:00 noon). In an emergency, call 911. A record of each visit is kept in your medical record.
Consent. ☐ I am 18 or older and located in Texas. ☐ I have read and understand this consent, and my questions were answered. ☐ I consent to telehealth.
Name: ______ Date: ______ Signature (e-signature): ______