Consent to Telehealth Services

If I am experiencing a medical emergency, I understand that I should contact 9-1-1, go to the nearest emergency room, contact my local crisis center, message the Crisis Text Line (text “GO” to 741-741 or if applicable, call the National Suicide Prevention Lifeline at 1-800-272-8255. I will not use Wisp’s platform for emergency medical services.

I have reviewed this Consent to Telehealth Services with respect to the provision of healthcare services from Wisp’s contracted medical professional entities (the professional entities collectively, "The Practices”) and their affiliated medical service providers (“Providers” or “Provider”). I understand that this consent is supplemental to the Medical Terms of Service and Wisp Terms of Service.

What is Telehealth? Telehealth is the provision of medical and healthcare services in which the patient and medical provider are not in the same location. To effectuate the provision of medical services in such circumstances, healthcare providers utilize technology, such as diagnostic tools, audio communication, visual communication, and/or store-and-forward technology. In some cases, telehealth services are performed synchronously (i.e., with the patient and provider interacting in real time) and in other cases telehealth services are performed asynchronously (i.e., with the patient and provider interacting at different times). Telehealth includes the creation and/or transmission of an electronic patient medical record. Not all conditions are suitable for treatment via telehealth.

By checking the box in the Wisp registration flow associated with this Consent to Telehealth, I consent to receive medical services via telehealth and agree to all statements, acknowledgements and disclosures set forth below:

• I know what telehealth includes. I understand that, where appropriate, care via telehealth includes a medical examination, consultation via electronic means, and the potential diagnosis and treatment of a medical condition.
• Telehealth has benefits and risks. I understand that treatment via telehealth is a choice. Treatment via telehealth has benefits, including: ease of scheduling, the ability to access my health records via an online portal and the ability to have a more seamless experience. Treatment via telehealth also has limitations and risks, including (i) the inability to have face-to-face, in-person contact between a provider and a patient; (ii) the potential for data breach; and (iii) the lack of a comprehensive, previously existing medical file from my in-person provider, which may have provided additional insights into treatment options.
• I will seek appropriate follow-up care. If I experience an adverse reaction, worsening symptoms, or need follow-up care after a telehealth visit, I will contact my Provider through the secure messaging portal, or seek appropriate in-person or emergency medical care.
• I know how to reconnect in the event of a technical failure. If there is a technical failure or interruption of the telemedicine platform, I will attempt to reconnect and, if unsuccessful, contact my Provider through the secure messaging portal or email support@hellowisp.com to request assistance or arrange follow-up care.
• Not all conditions are suitable for telehealth. I understand that in-person care is an alternative to telehealth and that not all conditions are suitable for telehealth. I recognize that my Provider may deem telehealth inappropriate for my specific case. I further understand that there is no guarantee that I will be prescribed any specific medication, and that any prescription or course of treatment is up to the medical and professional judgment of my Provider.
• I can withdraw my consent at any time. I understand that I can withdraw my consent for telehealth at any time without affecting my rights to future care, provided that I follow all applicable terms of service.
• A provider will be assigned to me. I understand that a Provider will be assigned to me. I can request a different, appropriately-licensed Provider, and I have the right to review the credentials of my assigned Provider or a Provider of my choice.
• I will provide accurate and complete information to my Provider. I acknowledge I am responsible for providing complete, accurate, and current information about my health, including my medical history, symptoms, allergies, and all medications or supplements I am taking.
• I will keep my Provider informed of changes. I will inform my Provider of any changes to my health status or medications that may affect my care.
• I understand my Provider is relying on the information I provide. I acknowledge that, in a telehealth setting, my Provider relies primarily on the information I provide and may not have access to my full medical record or the ability to independently verify information. Therefore, I understand my Provider’s clinical decisions are based on the information I provide.
• Certain services may require diagnostic laboratory testing. If laboratory testing is ordered, I will review and agree to the Laboratory Informed Consent Form before my sample is processed. The Laboratory Informed Consent Form is intended to supplement, and not replace, this Consent to Telehealth. The Laboratory Informed Consent Form must be acknowledged and agreed to prior to purchasing a laboratory product.
• Some medications may be globally sourced. I understand that in order to keep medication costs down, some of Wisp's mail-order partners may use pharmacies that globally source certain drugs prescribed to me. I understand that the product website and treatment guide will indicate whether my prescription is being sourced globally.
• I will review and follow all information provided to me about my prescription. I will follow all treatment instructions, including prescription directions, dosage guidelines, and any follow-up recommendations, and I acknowledge I am responsible for reviewing prescription information, warnings, and instructions provided by the pharmacy or manufacturer and for using medications only as directed.
• I am at least 18 years old. I hereby certify that I am at least 18 years of age and receiving treatment in the state to which I have requested the medication be shipped and delivered or sent to a local pharmacy.
• State of Residency. I understand and acknowledge that Wisp imposes eligibility requirements to comply with state law, and that I comply and will at all times comply with all relevant laws in accessing and utilizing the Wisp platform to receive a prescription and medication, including, without limitation, providing truthful information concerning my state of residency.
• Artificial intelligence may be used during my consultation. Wisp may disclose information received during a telehealth consultation with vendors that provide artificial intelligence services that provide backend support for our Services, including for administrative and informational purposes. Any such tools do not provide medical, clinical, diagnostic, treatment, or other regulated advice or services, and are not a substitute for advice from a qualified professional, including a medical professional. These tools are not intended to, and do not, engage in the practice of medicine or any other licensed profession.
• Session Recordings. I understand that my sessions with the Provider are not recorded, but that any interactions via phone or voicemail will be recorded by Wisp and its service provider.
• I can request transfers of my medical records. I understand that I can contact privacy@hellowisp.com for requests to transfer my medical records.
• I may receive text messages (via SMS and/or MMS) and calls. I agree to receive text messages and calls from or on behalf of Wisp at the phone number I provide to Wisp. I understand and agree that these texts/calls may be considered telemarketing under applicable law, that they may be sent using an automatic telephone dialing system or other automated technology and may use a prerecorded or artificial voice (including AI-generated voice), that my communications may be recorded by Wisp and its service providers, and that my consent is not a condition of any purchase. I understand that text messages are not secure forms of communication.
• I know how to ask questions. I have been given an opportunity to ask questions about the telehealth services to be provided to me, including any relevant risks and hazards involved with the provision of such services via secure messaging.

Additional Notices to Patients in the Following States: In addition to the information provided above, certain state laws require Wisp Affiliated Providers to provide additional information and disclaimers. I understand I should review the information and disclaimers provided below that apply to the state where I receive treatment and receive telehealth services from Wisp Affiliated Providers.

Alaska: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records. (Alaska Stat. § 08.64.364(a)(2)).

Arizona: I consent to treatment via telehealth and I evidence my consent via this electronic format. (Ariz. Rev. Stat. Ann. § 12-2291).

California: I consent to treatment via telehealth and I evidence my consent via this electronic format. Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov,email: licensecheck@mbc.ca.gov, or call (800) 633-2322. For more information visit the California Medical Board’s Notice to Consumers website.

Connecticut: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records. (Conn. Gen. Stat. Ann. § 19a-906). D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).

Georgia: I understand that I am entitled to receive clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to treatment via electronic or other means. (Ga. Comp. R. & Regs. 360-3-.07(7)). I understand that I have the right to file a grievance with the Georgia Composite Medical Board concerning my Provider and the treatment I receive. To file a grievance, I understand I should send a written complaint to the board and I should be able to provide the name of my Provider and the specific nature of the complaint. Complaints or grievances may be reported to the Board at the following address or telephone number: Georgia Composite Medical Board Attn: Complaints Unit 2 Martin Luther King Jr. Drive SE 11th floor, East Tower Atlanta, GA 30334 (404) 656-3913 www.medicalboard.georgia.gov
(Ga. Comp. R. & Regs. 360-27-02).

Idaho: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, here: https://bom.idaho.gov/BOMPortal/AgencyAdditional.aspx?Agency=425&AgencyLinkID=650

Indiana: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, here: https://www.in.gov/attorneygeneral/2434.htm

Iowa: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, Here: https://medicalboard.iowa.gov/consumers/filing-complaint

Kansas: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records, and my Provider shall send within three business days a report to my primary care or other treating physician of the treatment and services rendered to me in my telehealth encounter. (Kan. Stat. Ann. § 40-2,212(d)(2)(A).

Kentucky: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, here: https://kbml.ky.gov/grievances/Pages/def ault.aspx

Louisiana: I understand that the relationship between provider and patient is one that is governed by various laws and codes of ethics. I understand and consent to the fact that other health care providers may be involved in the management of my treatment. I further understand that I may decline to receive medical services via telemedicine and may withdraw from such care at any time. (46 La. Admin. Code Pt XLV, § 7511).

Maine: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, Here: https://www.maine.gov/md/discipline/file-complaint.html

Nebraska:: I understand the statements provided in this Consent to Telehealth Services and have discussed them with my medical service provider. I understand that I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. I understand that all existing confidentiality protections shall apply to my telehealth consultation. I expressly consent to the dissemination of any of my identifiable images or information from the telehealth consultation to third parties. I understand that I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. (Neb. Rev. Stat. § 71-8505).

New Hampshire: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records. I understand that I may discuss with my Provider whether this is appropriate for my situation. (N.H. Rev. Stat. § 329:1-d).

New Jersey: I understand that I have the right to request a copy of my medical information and, if deemed appropriate by my Provider, I affirmatively consent to having my medical information forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. I understand that the telemedicine encounter may be with a medical service provider who is not a physician and that I may specifically request that the telemedicine encounter be scheduled with a physician. I understand that if I don’t have a primary care provider or other health care provider of record, my Provider may advise me to contact a primary care provider, and, upon request by me, my Provider may assist me with locating a primary care provider or other in-person medical assistance that, to the extent possible, is located within reasonable proximity to me. I understand that I shall contact my Provider directly to arrange for the transmission of these records. (N.J. Rev. Stat. Ann. § 45:1-62).

Oklahoma: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website, here: http://www.okmedicalboard.org/complaint With respect to the Board of Osteopathic Examiners I understand that they may be reached here: https://www.ok.gov/osboe/faqs.html

Oregon: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website here:
https://www.oregon.gov/omb/investigations/pages/investigations-overview.aspx.

Rhode Island: I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website here: https://health.ri.gov/licensing/submit-complaint. I consent to the use of e-mail or text-based technology to communicate with my Provider,and I understand that various types of transmissions will be permitted, including but not limited to, prescription refills, appointment scheduling, and patient education. I further understand that alternate forms of communication or office visits may be utilized, such as when I or my Provider do not deem telehealth an appropriate medium for my consultation, diagnosis or treatment. I have reviewed Wisp’s and the Practices’ data security measures and I understand various measures may be used, such as encryption of data and utilization of other reliable authentication techniques. I have been warned of potential risks to privacy notwithstanding the security measures. I agree to hold harmless my Provider, the Practices’, Wisp Affiliated Providers, and Wisp for information lost due to technical failures; and I provide my express consent to forward my patient-identifiable information to a third party. I acknowledge that my failure to comply with this agreement may result in my Provider terminating my patient-provider relationship. (Rhode Island Medical Board Guidelines).

South Carolina: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records. I understand that my medical records may only be distributed in accordance with applicable law. (S.C. Code Ann. § 40-47-37).

South Dakota: I have received and understood disclosures regarding the delivery models and treatment methods or limitations. that may be used by the Provider. (S.D. Codified Laws § 34-52-3).

Texas: If I consent to transferring my medical records to another provider, I understand that I shall contact my Provider directly to arrange for the transmission of these records. (Tex. Occ. Code Ann. § 111.005). Furthermore, I have received and reviewed the following notice: NOTICE CONCERNING COMPLAINTS - Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board Attention: Investigations 1801 Congress Avenue, Suite 9.200 P.O. Box 2018 Austin, Texas 78768-2018
Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at: www.tmb.state.tx.us. AVISO SOBRE LAS QUEJAS Quejas sobre médicos, así como sobre otros profesionales médicos de la Junta Médica de Texas, incluyendo asistentes medicos profesionales, acupunturistas, asistentes quirúrgicos, tecnólogos médicos en radiología, técnicos radiólogos no certificados, profesionales de cuidados respiratorios, físicos médicos, y perfusionistas se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board Attention: Investigations 1801 Congress Avenue, Suite 9.200 P.O. Box 2018 Austin, Texas 78768-2018 Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353 Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

Utah: I have been informed of (i) additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately; (ii) to whom my health information may be disclosed and for what purpose; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations, as provided in among other places this Consent to Telehealth Services and any applicable terms of use. I understand that the telehealth services the Practices provide meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). I have been warned of potential risks to privacy notwithstanding the security measures. I understand that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. I have been provided with the location of Wisp’s website owner-operator, location and contact information. I understand that Wisp and the Practices work with third parties to receive patient identifiable information related to the services provided, including but limited to the fulfillment of any prescriptions. I understand that Other such disclosures are provided in policies and terms of service associated with this platform. (Utah Admin. Code r. 156-1-602).

Vermont: I understand that understand that one Provider will lead my telehealth consultation, and I consent to other qualified Providers within the Practices to participate in my care or addressing my follow-up questions.I understand that all services my Provider delivers to me through telemedicine will be delivered over a secure connection that complies with the requirements of HIPAA. I understand that receiving store-and-forward telehealth services via the Practices does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361). If deemed appropriate by my Provider, I consent to a telephone consultation (as opposed to a video consultation) to receive care via telemedicine. I understand that various types of transmissions may be used by my Provider, including but not limited to, prescription refills, appointment scheduling and patient education. I agree that my Provider will determine, consistent with applicable laws, whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter. I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures. I understand there is a risk of loss of information due to technical failure. I expressly consent to allow Wisp Affiliated Providers to forward my patient-identifiable information to third parties, limited by and only if allowed under all applicable state and federal laws. (Vermont Board of Medical Practice Guidance). I understand that in order to make a formal complaint about a provider, I should visit the medical board’s website here: https://sos.vermont.gov/opr/complaints-conduct-discipline and here with respect to osteopathic professionals:
https://outside.vermont.gov/dept/sos/office_professional_regulation/discipline_resources_reports/opr-mandatory-reporting-form-2015-12-08.pdf

Virginia: I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; I agree to hold harmless my Provider, the Practices, Wisp Affiliated Providers, and Wisp for information lost due to technical failures; and I provide my express consent to forward my patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).

Last Revised Date: 5/6/2026