Prescription Disclosure Template

What You Are Purchasing

You are paying for a telehealth consultation with a licensed provider. You are not guaranteed a prescription. The consultation fee is due regardless of the outcome.

How the Consultation Works

1. You complete a medical intake questionnaire.
2. A licensed provider reviews your intake asynchronously.
3. The provider may approve, decline, or request additional information (including a synchronous visit).
4. If approved, the prescription is transmitted to a partner pharmacy for fulfillment.

Provider Independence

Providers exercise independent medical judgment. {{Brand}} does not direct clinical decisions and does not pay providers on a per-prescription basis.

Safety

You must disclose all current medications, medical conditions, and pregnancy status. Withholding information may lead to serious harm.

Right to Decline

You may withdraw at any point before the provider begins review and receive a full refund.