Telehealth Informed Consent

Prisk Orthopaedics and Wellness, PC ("P.O.W., PC"), doing business as POWFIT MD Providers: Victor Prisk, MD (Medical Director) and Elizabeth Headlee, CRNP 2490 Mosside Blvd., Monroeville, PA 15146 | powfitmd.com

Pre-launch draft date: August 22, 2026

Working draft: This document is undergoing Pennsylvania healthcare-counsel review. It is not approved for patient enrollment or a clinical launch.

Please read this document carefully before your first telehealth visit. It explains what telehealth is, its benefits and limitations, the technology we use, and your rights. Pennsylvania's Telemedicine Act (Act 42 of 2024) authorizes health care delivered by telemedicine and holds telehealth providers to the same standard of care as in-person care (PA Act 42). We ask you to review and sign this consent before receiving telehealth services, and we will document your consent in your medical record.

1. What Telehealth Is - and Its Limits

Telehealth means receiving medical evaluation, consultation, treatment, and follow-up from a licensed clinician using secure electronic communications - most commonly live (synchronous) video visits, and in some cases secure messaging, transmitted photos, and remote monitoring data (asynchronous/store-and-forward).

Telehealth has real benefits: convenience, faster access, and continuity of care. It also has limits you should understand:

Your clinician cannot perform a hands-on physical examination during a video visit. Some conditions, medications, and situations require an in-person examination, and your clinician will tell you when that applies.
Diagnosis and treatment by telehealth depend on the accuracy and completeness of the information you provide, including history, photos, home measurements, and laboratory results.
Technical failures (dropped connections, poor video quality) may delay or interrupt care. If a visit cannot be completed adequately, we will reschedule or convert it to an in-person visit at no penalty to you.
In rare cases, security protocols can fail. We use approved encrypted technology and require appropriate vendor safeguards and agreements before PHI is processed, but no electronic system is perfectly secure.

2. The Technology We Use

Video visits: conducted through a Practice-approved video service disclosed to you before the visit. A platform is not used for PHI until its exact service, configuration, safeguards, and required agreements are approved.
Patient portal: our POWFIT MD portal uses approved Google Cloud services for intake, scheduling, subscriptions, and secure messaging. Your medical record itself is maintained in our electronic health record, ModMed (Modernizing Medicine).
Website help: the current public website helper presents prewritten navigation and support choices; it is not a free-form medical chatbot. Do not enter medical details into a public help field.
AI phone assistant: not currently enabled for the new platform. See Section 8.

AI role - important: If POWFIT MD later enables an AI-assisted administrative feature, it will be separately disclosed and will remain subject to human oversight. All clinical decisions - diagnosis, treatment, prescribing - are made exclusively by our licensed clinicians. No AI tool may diagnose you, select your treatment, determine a dose, or issue a prescription.

3. Your Right to Choose In-Person Care

Telehealth is voluntary. You may decline or stop telehealth at any time without losing access to care. POWFIT MD is a hybrid practice: in-person visits are available at our Monroeville-area office, and certain services (for example, some initial evaluations, examinations required before certain prescriptions, and some aesthetics services) are offered in person. Declining telehealth will not affect your right to future care, and no benefits you are otherwise entitled to will be withdrawn.

4. Emergencies

Telehealth is not for emergencies. If you are experiencing a medical emergency - chest pain, difficulty breathing, stroke symptoms, severe allergic reaction, thoughts of harming yourself or others - call 911 immediately (or 988 for the Suicide & Crisis Lifeline). Portal messages, website help, ordinary phone messages, and scheduled visits are not monitored continuously and must not be used for urgent or emergency situations. At the start of each video visit we will confirm your physical location so emergency services can be directed to you if needed.

5. Prescriptions

Any prescription is issued only if, in the clinician's independent judgment, it is medically appropriate. A membership or program fee never guarantees a prescription.
The POWFIT MD portal does not itself prescribe. When a clinician issues a controlled-substance prescription, it is transmitted through an approved certified electronic prescribing (EPCS) workflow except where law recognizes a specific exception. The Practice will not prescribe when required enrollment, identity, examination, PDMP, or transmission controls are unavailable. Non-controlled prescriptions use an approved electronic or other legally permitted secure workflow.
Controlled substances via telehealth: Under the current federal telemedicine flexibilities (extended through December 31, 2026), a DEA-registered prescriber may prescribe controlled substances following a real-time audio-video evaluation without a prior in-person exam (Federal Register, Dec. 31, 2025). However, Pennsylvania regulations require an initial medical history and physical examination before controlled substances are prescribed (49 Pa. Code § 16.92), and you may therefore be required to complete an in-person examination - at our Monroeville-area office or with a local partner - before starting or continuing testosterone, phentermine, or any other controlled medication. Federal rules may also change after December 31, 2026, and our prescribing policies will change with them.
Pennsylvania's prescription drug monitoring program (PDMP) will be checked as required by law before controlled substances are prescribed.
Compounded medications, when prescribed, are patient-specific prescriptions filled by a qualified pharmacy selected by the patient and able to lawfully fill the prescription. Compounded drugs are not FDA-approved products; your clinician will discuss risks and alternatives. POWFIT MD does not offer a standard compounded GLP-1 program. Any exception involving a commercially available drug requires a documented patient-specific clinical need and confirmation that the prescription and pharmacy pathway are lawful.

6. Laboratory Requirements for Hormone Therapy

Safe hormone therapy requires objective data. If you are evaluated for testosterone replacement therapy (TRT) or hormone replacement therapy (HRT), you agree to complete required baseline and periodic laboratory testing - for TRT this includes two separate morning testosterone measurements before diagnosis, consistent with clinical guidelines, plus ongoing monitoring labs. Failure to complete required labs or follow-up visits may result in prescriptions being paused or discontinued for your safety. Periodic labs are included in the applicable membership as described in your membership terms.

7. Risks and Benefits - Summary

Potential benefits: improved access and convenience; continuity with a local, physician-led practice; efficient monitoring of ongoing therapy; reduced travel and waiting.

Potential risks: limitations of examination without touch; technology failure or interruption; rare security/privacy failures despite safeguards; delays if in-person follow-up is needed; the possibility that telehealth information is insufficient and in-person evaluation is required. Your clinician will convert your care to in-person whenever telehealth is not clinically adequate.

8. Phone Calls, Recording, and Automated Processing

POWFIT MD does not currently use an AI voice agent or routine automated call recording/transcription for the new platform. If either feature is enabled, the Practice will provide a separate notice, obtain the consent required for that communication, explain data use and retention, and offer a non-automated alternative before recording or AI processing begins. Accepting this telehealth consent alone does not enroll you in a future recorded or AI-processed call.

9. Financial Consent

POWFIT MD is a direct-pay (cash-pay) practice. We do not bill insurance, and membership fees are not submitted to your insurer. Current membership pricing (subject to change with notice, and stated in your membership agreement): Men's hormone optimization/TRT approximately $149/month including periodic labs; Women's HRT approximately $129/month; Medical weight loss approximately $199/month program fee with medication costs separate; aesthetics and wellness services priced a la carte. A one-time $99 initiation fee applies when you enroll in a TRT, HRT, or weight-loss membership; it covers your comprehensive intake visit (including an in-person examination where required) and is refundable under the new-member guarantee in the Terms of Service if you cancel before your first clinical visit is completed. Aesthetics a la carte services carry no initiation fee.
Payments and subscriptions are processed by Stripe; your card data goes directly to Stripe and is not stored by the practice. Charges appear with generic descriptions.
Cancellation, refund, and billing-dispute terms are set out in our Terms of Service / Membership Agreement, which governs financial matters. A membership fee pays for access to clinical services and program management; it does not purchase a particular prescription or outcome.

10. Where We Can Treat You

Our clinicians can treat you by telehealth only when you are physically located in a state where the treating clinician is licensed. At present, services are offered to patients located in Pennsylvania. You agree to tell us your physical location at each visit and to update us if you move or travel. If you are outside a licensed state, we may need to reschedule or arrange alternative care.

11. Privacy

Your health information is protected under HIPAA and handled as described in our Notice of Privacy Practices and website Privacy Policy, both available at powfitmd.com. Prescriptions and necessary demographics are shared with your pharmacy as part of treatment.

Patient Acknowledgment and Consent

By signing below (or by electronic signature/click-acceptance in the POWFIT MD portal, which has the same effect), I confirm that:

I have read and understand this Telehealth Informed Consent, and I have had the chance to ask questions and have them answered.
I voluntarily consent to receive health care services from Prisk Orthopaedics and Wellness, PC d/b/a POWFIT MD via telehealth, and I understand I may withdraw this consent at any time and choose in-person care instead.
I understand the limitations of telehealth, including that in-person examination may be required - including before controlled-substance prescriptions - and that telehealth is not for emergencies (call 911).
I understand that any future AI-assisted tool is administrative only and that all clinical decisions are made by licensed clinicians.
I understand that this document does not itself consent me to future recorded or AI-processed calls; the Practice will provide a separate notice and obtain the consent required before such processing.
I understand and accept the financial terms in Section 9, including that this is a cash-pay practice and that fees do not guarantee any prescription or outcome.
I confirm that I am at least 18 years of age and will be physically located in a state where my POWFIT MD clinician is licensed at the time of each telehealth visit.

Patient Name: ______________________________ Date of Birth: ______________

Signature: ______________________________ Date: ______________

State where you will be located during telehealth visits: ______________

Reviewed by (staff/clinician): ______________________________ Date: ______________