Telemedicine Informed Consent

Thank you for choosing Vincere Vita llc! you are viewing this form because you are receiving treatment from one of our a healthcare practitioners via the Vincere Vita platform.

by clicking “i agree,” you acknowledge that you have read, understand, and agree to the following:

what is telemedicine?

telemedicine is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than a healthcare provider. the vincere vita platform allows you to receive treatment from a physician without having to travel to another location or schedule a separate appointment and helps you avoid long wait times that you might otherwise experience at an in-person visit.

your healthcare practitioner will conduct your treatment through in-depth questionnaires, review of lab results, and follow up text-based communications through the patient portal.  vincere vita’s platform does not provide for video or audio visits. your treatment via telemedicine may include prescriptions, labs, refills, education, and diagnosis.

by clicking “i agree,” you agree to receive care via telemedicine from [vincere vita llc] and the physician above through the vincere vita platform.

what are the possible risks to using telemedicine?

as with any medical treatment, there are potential risks associated with the use of telemedicine. your physician believes that the likelihood of these risks materializing is very low.

these risks may include, without limitation, the following:

delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment which may include poor video and data quality.

security protocols could fail, causing a breach of privacy of personal medical information.

lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other negative outcomes.

your rights and acknowledgements:

you have the same privacy rights via telemedicine that you would have during an in-person visit.

telemedicine may involve electronic communication of your personal medical information to medical practitioners who may be located in other areas, including out of state.

you understand that you may expect the anticipated benefits from the use of telemedicine, but that no results can be guaranteed or assured.

you understand that all information will be part of your medical record and available to you by printing the summary from the visit. this information will have the same restrictions on dissemination without your consent.

except to the extent already relied upon, you understand you may withdraw your consent at any time by emailing to withdraw your consent and inactivate your account.

you understand that your healthcare information may be shared with other individuals for treatment, payment and healthcare operations purposes, including laboratories for ordering and sharing lab results, pharmacies for filing prescriptions, and billing providers for processing payments.

you further understand that your healthcare information may be shared in the following circumstances:

when a valid court order is issued for medical records.

reporting suspected abuse, neglect, or domestic violence.

preventing or reducing a serious threat to anyone’s health or safety.

this telemedicine informed consent is valid during your entire treatment with your healthcare practitioner via the vincere vita platform.

i have read and understand the information provided above, and understand the risks and benefits of telemedicine, and by accepting these terms of use i hereby give my informed consent to participate in a telemedicine visit under the terms described. by clicking the “agree” button you are consenting to receiving care via the service. the scope of care will be at the sole discretion of the healthcare physician who is treating you, with no guarantee of diagnosis, treatment, or prescription. the healthcare physician will determine whether or not the condition being diagnosed and/or treated is appropriate for a telehealth encounter via the service.

authorization of disclosure of personal data

by clicking ‘i accept’, you hereby authorize vincere vita llc to disclose your information, including healthcare and other medical information, to a healthcare provider(s) and those third-party entities listed in the privacy policy for the purposes outlined in therein.

this authorization will remain in effect until 2050, or until you revoke such authorization in writing, after which vincere vita llc will no longer be authorized to disclose your medical information until and unless you execute another authorization.

you have the right to receive a copy of this authorization upon request. should you wish to receive a copy of this authorization, please send a request to”

healthcare provider disclaimer

when the user is connected to a healthcare provider, you should have two pop ups:  

1.emergency disclaimer:

“if you have a life-threatening emergency, do not use this platform. call 911.

by continuing to use the platform, you are acknowledging that the medical issue for which you are seeking help is not an emergency, life-threatening or critical.  please also note that the healthcare provider’s ability to diagnose and/or treat you may be impaired due to limitations inherent in the technology.”healthcare provider disclaimer:

  1. healthcare provider disclaimer:

“vincere vita llc is not your healthcare provider. All clinical decisions and provision of health care services are the responsibility of the healthcare provider with whom you are connected via the platform. You should direct all questions regarding your care to the healthcare provider providing the clinical care.”

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