Consent Form Regarding Telehealth Services

I, the patient, understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to Custom Medical Group LLC (a partner of and their physicians to provide health care services to me via telemedicine.

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time. I may revoke my consent in writing at any time by emailing As long as this consent is in force (has not been revoked) my provider may provide health care services to me via telemedicine without the need for me to sign another consent form.


I understand that Custom Medical Group and its affiliates have consent to send medical records to your primary care physician.

I understand that the identity and credentials of my Custom Medical Group healthcare provider is provided through email correspondence when a written request is submitted to our medical team at

The Custom Medical Group electronic network incorporates specific network and software security protocols to protect and ensure the privacy of individual’s health information. The Custom Medical Group has implemented systems to ensure that this information will be kept safe from data breaches.

Emergencies and Follow-Up Care:

Telemedicine is not the appropriate course of action in certain medical scenarios. This includes, but is not limited to immediate medical situations, allergic or adverse reactions, telemedicine technology failures and the inability to get into contact with your telemedicine provider. In these scenarios, please contact your primary care provider or go to your local hospital. If the situation is a medical emergency, dial 911 immediately.

The Benefits of Telemedicine Include:

  • Improved and convenient access of health services to patients

  • Reduced healthcare costs, including lowered costs for online visits and prescriptions

  • Online interactions eliminate the need for in-office appointments and travel times

  • Increased efficiency in diagnosing, consulting and prescribing

The Potential Risks of Telemedicine are rare but Include:

  • Delays in patient evaluation may occur due to technology failures

  • Patient privacy breaches may occur due to failures in security protocols and/or safeguards

  • Specific regulatory requirements in certain jurisdictions can limit or prevent prescribing certain medications


You agree to indemnify, defend and hold harmless Custom Medical Group and its officers, directors, employees, consultants, representatives and agents, and other users and visitors of the Website, from and against any and all third-party claims, liabilities, damages, losses, costs, expenses, fees (including reasonable attorneys’ fees and court costs) that such parties may incur as a result of or arising out of or related to (a) any information you submit, post or transmit through the Website, (b) your use of the Website and/or Products, (c) your violation of any provision of these Terms of Service, (d) your violation of any rights of any other person or entity, or (e) any viruses, Trojan horses, worms, time bombs, cancelbots or other similar harmful or deleterious programming routines input by you into the Website.

By Clicking “I Consent” as the Patient, you Agree to the Following:

  • I understand that the same confidentiality and privacy protections that are in place for other healthcare services also apply to telemedicine services.

  • I understand that I have full access to all of my health records that pertain to my telemedicine services in accordance with applicable state laws and regulations.

  • I understand that unless I revoke my consent, this informed consent will be renewed upon each new telemedicine consultation and service.

  • I agree to allow my telemedicine provider to share my healthcare information with other individuals as it applies for treatment, payment and healthcare operation purposes.

  • I understand and consent to the foregoing acknowledgments and disclosures including the Terms of Service and Notice of Privacy Practices.

  • I have read through this special Informed Consent carefully and understand both the risks and benefits of the telemedicine services Custom Medical Group will provide me.

  • I understand that telemedicine is a rapidly evolving field and there may be technology used that is not specifically described in this consent.

  • I understand that although telemedicine may provide benefits for me, I also am aware that no such benefits or results can be guaranteed.

  • I understand that I may not be a suitable candidate for Custom Medical Group’s  telemedicine services and treatments, and that I may need to seek medical care and treatment in-person or from an alternative source.

  • I understand that in certain instances my prescription may be provided through a consultation by a licensed medical specialist in another jurisdiction at the request of a Custom Medical Group Team Member at no additional cost

  • I give my informed consent to the use of telemedicine by providers affiliated with Custom Medical Group.

  • I understand that this will stand as the equivalent of my electronic signature.

Healthcare doesn't have to be a pain, expensive, embarrassing, or inconvenient. is a unique service started by passionate entrepreneurs in 2014 to help people get access to convenient, affordable, chewable tablets for more confidence in bed. Members of BlueChew get access to a medical team trained in diagnosis and treating patients with custom treatments for improved sexual confidence.

The healthcare system in the US is broken and needs to be re-imagined with the patient in mind.  Our tech and support teams are laser focused on making accessibility to prescription treatments made in the form, flavor, dosage, and active ingredients that are right for the patient.

Insert Content Template or Symbol