Effective date: September 29, 2025
BY CLICKING "I AGREE," CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE "I AGREE" BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.
IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION SUCH AS CONTEMPLATING SUICIDE, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE AT 988.
Purpose
The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you by physicians, physician assistants, nurse practitioners (“Providers”) using the online platforms owned and operated by Peak Revival Plus LLC (the “Service”). In this Consent, the terms “you” and “yours” refer to the person using the Service.
Use of Telehealth
Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and patient education, and may include one or more of the following: electronic transmission of medical records, photo images, personal health information or other data between a patient and a provider; interactions between a patient and provider via audio, video and data communications such as messaging or email; use of output data from medical devices, sound and video files. Alternative methods of care may be available to you, such as in-person services, and you may choose an alternative at any time. Always discuss alternative options with your Provider.
Anticipated Benefits
The use of telehealth may have possible benefits that include making it easier and more efficient for you to access medical care or other services and treatment for the conditions treated by your Provider, allowing you to obtain care at times that are convenient for you, and enabling you to interact with Providers without the necessity of an in-office appointment.
Potential Risks
While telehealth can provide benefits, there are potential risks that include the following:
The quality, accuracy or effectiveness of the services you receive from your Provider could be limited.
Technology, including the Service, may contain bugs or other errors that may limit functionality, produce erroneous results, render the Service unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost.
Failures of technology may impact your Provider's ability to correctly diagnose or treat your condition.
The inability to conduct certain tests or assess vital signs in person may prevent diagnosis or treatment or the identification of the need for emergency medical care.
Your Provider may not be able to provide treatment for your particular condition and you may be required to seek alternative healthcare or emergency services.
Mental health services may result in feeling worse as therapy progresses.
Delays in medical evaluation or treatment could occur due to unavailability of your Provider or failures of technology or equipment.
Electronic systems or other safeguards could fail, causing a breach of privacy of your medical or other information.
Data stored and communicated electronically, for example through email, may be more susceptible to unintended disclosure to third parties.
Regulatory requirements in certain jurisdictions may limit diagnosis and treatment options, especially regarding certain prescriptions.
A lack of access to all of your medical records may result in adverse drug interactions, allergic reactions, or other judgment errors.
LIFE THREATENING AND OTHER EMERGENCY SITUATIONS; FOLLOW-UP CARE
If you are experiencing a life-threatening situation such as contemplating suicide, call 911 or the 988 Suicide and Crisis Lifeline at 988.
If the situation is an emergency, call 911. In some situations, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must seek care at an emergency room facility or another provider equipped to deliver urgent or emergent care. Providers may not respond promptly to communications you submit through the Service. If you are not experiencing an emergency or do not require immediate or urgent care, you can communicate with Providers through the secure message service in the Service.
Data Privacy and Protection
The electronic systems used in the Service incorporate network and software security protocols to protect the privacy and security of your information and include measures to safeguard data against intentional or unintentional corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for consultation, treatment, payment or billing, certain administrative purposes, and as required by law to disclose to other persons and agencies certain information obtained during the provision of mental health services such as danger to self or others and mandatory reporting of child, elder, or vulnerable adult abuse, or as otherwise set forth in your Provider's Notice of Privacy Practices. Use of the Service may include email communications to and from you that may include your protected health information. You understand that Peak Revival Plus does not and cannot guarantee the security or privacy of the services you use to receive communications, including for example your email service provider.
Your Acknowledgments
By clicking "I Agree", checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service or otherwise affirmatively accepting this Consent, you agree and provide your consent to the following:
Healthcare services provided to you by Providers via the Service will be provided by telehealth.
In some cases, your treating Provider may be a nurse practitioner or physician assistant and not a physician, and you agree to be treated by non-physician providers when applicable by using the Service. Your treating Provider for therapy services will be a mental health professional such as a licensed counselor.
Certain technology, including the Service, may be used while still in a beta testing and development phase and before such technology is a final product.
Technology used to deliver care, including the Service, may contain bugs or other errors that may limit functionality, produce erroneous results, render the technology unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost. Any of these could limit or impact the quality, accuracy and effectiveness of the care or services that you receive from your Provider.
Certain diagnostic testing services, including laboratory products and services offered through the Service, may contain defects that may limit functionality or produce erroneous results, which could impact the quality, accuracy and effectiveness of your care.
The delivery of healthcare services via telehealth is an evolving field, and uses of technology in your care may include approaches different from those described in this Consent.
No potential benefits from the use of telehealth or specific results can be guaranteed, including any laboratory testing results or related diagnosis or treatment. Your condition may not be cured or improved and may in some cases worsen.
There are limitations in the provision of care via telehealth and technology, including the Service, and you may not be able to receive diagnosis or treatment through telehealth for every condition.
There are potential risks to the use of telehealth and technology, including the risks described in this Consent.
You have the opportunity to discuss the use of telehealth, including the Service, with your Provider, including benefits, risks and alternatives.
There will be no recording of any online treatment sessions by your Provider or by you.
Your Provider will assess your condition and, in their sole discretion, may determine it is medically appropriate to diagnose or treat your condition via telehealth and whether you maintain sufficient knowledge and skills in the use of technology appropriate to diagnosing or treating your condition via telehealth. By continuing to use the Service, you concur with your Provider's medical assessment and agree to receive diagnosis or treatment via telehealth technology.
You have the right to withdraw your consent to the use of telehealth in the course of your care without prejudice to future care or treatment and without risking the loss or withdrawal of any health benefits to which you are entitled, but you understand that the Providers who utilize the Service do not offer in-person treatment. Any withdrawal of consent will be effective upon receipt of written notice to your Providers, except that such withdrawal will not affect actions taken by Peak Revival Plus or your Provider in reliance on this Consent before receipt of your written notice. Withdrawal of consent will not affect any other provision of this Consent, and you will continue to be bound by it.
The Service involves electronic communication to and from you of your personal medical information in connection with the provision of telehealth services, including through email.
It is your duty to provide Peak Revival Plus and your Providers truthful, accurate and complete information, including relevant information about care that you have received or are receiving from healthcare or mental health providers, including emergency contact information for your local providers.
Each of your Providers will assess your condition and, in their sole discretion, may determine it is medically appropriate to diagnose or treat your condition using telehealth technology, including the Service. By continuing to use the Service, you concur with your Provider's medical assessment and agree to receive diagnosis or treatment via telehealth technology.
Each of your Providers may determine in their sole discretion that your condition is not suitable for diagnosis or treatment using telehealth technology, including the Service, and that you may need to seek care and treatment from a specialist or other healthcare provider outside of telehealth technology.
Peak Revival Plus will use its pharmacy partners to fulfill your order directly to your door. You are free to obtain your prescription from any pharmacy of your choice by contacting our support team and notifying your prescribing healthcare professional directly using the Platform and your secure messaging. Prescriptions may be filled by and transferred between any pharmacy partners on your behalf. You must pay the full amount of the costs associated with use of the Service, including any prescription you may receive, and you will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer.
If you have a concern about a medical professional, you may contact the Medical Board in your state regarding your concerns.
Peak Revival Plus does not provide doctor consultations. Consultations are done through Beluga Health and DrTelx.
