Effective Date: October 1, 2026 | Version 1.0
This Telehealth Informed Consent Agreement (“Consent”) is entered into between you (“Patient”) and Fortem Medical PC, a professional corporation providing telehealth services through the Fortem Health platform operated by Fortem Group LLC DBA Fortem Health (“Fortem Health”). By submitting your intake form and proceeding with services, you acknowledge that you have read, understood, and agree to the terms of this Consent.
1. Nature of Telehealth Services
Telehealth involves the delivery of healthcare services using electronic communications technologies, including but not limited to secure asynchronous messaging, digital health intake platforms, electronic health records, and laboratory data integration. Your licensed provider will evaluate, diagnose, and treat you without being physically present in the same location. You understand and acknowledge that the practice of medicine via telehealth is subject to the laws and regulations of the state in which you are located at the time services are rendered.
2. Scope of Consent
By proceeding, you consent to each of the following:
- The delivery of healthcare evaluation, diagnosis, and treatment recommendations through telehealth, including asynchronous (non-real-time) clinical review by a licensed nurse practitioner or physician;
- The collection, storage, and use of your protected health information as described in our Notice of Privacy Practices;
- The electronic transmission of your health information between Fortem Health, your licensed provider, our licensed compounding pharmacy partner(s), and our laboratory partner(s) as necessary to coordinate and fulfill your care;
- The prescribing of medications, where clinically appropriate, based on your intake information, laboratory results, and your provider’s independent clinical judgment, which may occur without an in-person physical examination;
- The use of a clinical support platform to assist your provider in reviewing your health information and preparing clinical summaries, subject to final review and authorization by your licensed provider.
3. Risks and Limitations of Telehealth
You acknowledge that telehealth services involve inherent risks and limitations that differ from traditional in-person care, including without limitation:
- Interruptions, delays, or failures in electronic communication that may affect the delivery of care;
- Security risks associated with electronic transmission of health information, notwithstanding our implementation of industry-standard safeguards;
- The inability of your provider to conduct a comprehensive in-person physical examination, which may, in some circumstances, limit their capacity to diagnose or treat certain conditions via telehealth;
- The possibility that your provider may determine, in their sole clinical discretion, that telehealth is not appropriate for your situation and may decline to prescribe or may refer you to in-person care.
4. Provider Independence and Clinical Discretion
All clinical decisions, including decisions to prescribe or decline to prescribe any medication, are made solely by your licensed provider in the exercise of their independent professional judgment. Fortem Health does not direct, control, or influence clinical decision-making. No treatment or prescription is guaranteed as a result of your enrollment or intake submission.
5. Medications and Pharmacy Fulfillment
Where your provider determines that a prescription is clinically appropriate, your medication will be compounded and dispensed by a licensed compounding pharmacy and shipped directly to your address on file. Medication costs are included in your monthly membership fee. Laboratory services, where required, are fulfilled by our laboratory partner and billed separately at their published rates. Fortem Health does not mark up medication or laboratory costs.
6. State Licensing and Jurisdictional Compliance
Fortem Health provides telehealth services only in states where our providers hold active, unrestricted licensure and where applicable state law permits telehealth prescribing for your requested protocol. By submitting your intake, you represent that you are physically located in an eligible state at the time of service. Receipt of services in a jurisdiction where such services are not authorized is solely your responsibility.
7. No Emergency Services
Fortem Health is not an emergency medical service and is not equipped to respond to medical emergencies. If you are experiencing a medical emergency, you must immediately call 911 or proceed to the nearest emergency room. Do not use the Fortem Health platform or care team messaging system to report a medical emergency.
8. Right to Withdraw Consent
You may withdraw this Consent at any time by submitting a written request to care@myfortemhealth.com. Withdrawal of Consent will result in the discontinuation of telehealth services. Withdrawal will not affect the validity of care already provided or obligations already incurred prior to the date of withdrawal.
9. Acknowledgment
By submitting your intake form and proceeding with Fortem Health services, you confirm that: (a) you have read and understood this Consent in its entirety; (b) you have had the opportunity to ask questions and have them answered to your satisfaction; (c) you voluntarily consent to receive telehealth services under the terms described herein; and (d) you are at least 18 years of age.
Contact
Fortem Group LLC DBA Fortem Health
care@myfortemhealth.com
myfortemhealth.com