Telehealth Informed Consent

1. What telehealth is

Telehealth means receiving health care services from a licensed clinician using interactive audio-video technology while you and the clinician are in different locations. At Purelivity Wellness, telehealth includes live video visits, secure messaging, electronic ordering of laboratory tests, electronic prescribing, and remote review of your health information. Telehealth is a mode of delivering care — the professional and legal standards of care are the same as for an in-person practice.

2. Who provides your care

Purelivity Wellness is a nurse practitioner–led practice. Your care is provided by Tessa Rydberg, MSN, APRN, FNP-C (Texas license 1057505), a Texas-licensed, board-certified nurse practitioner registered with the U.S. Drug Enforcement Administration (DEA) to prescribe controlled medications. As Texas law requires, the practice operates under a Prescriptive Authority Agreement (PAA) with a collaborating Texas physician, who is available for consultation and periodically reviews prescribing practice and selected patient charts as part of routine quality assurance.

3. Requirements specific to testosterone (a controlled medication)

Testosterone is a Schedule III controlled substance under federal and Texas law. Because of that, the following are conditions of treatment at this practice, and you consent to each of them:

• Live audio-video examination. A prescription can only be issued after a live, interactive audio-video visit with your prescriber. We do not — and legally may not — prescribe testosterone based on a questionnaire, text messages, or an asynchronous form alone.
• Laboratory confirmation. Diagnosis requires two separate morning blood draws demonstrating low testosterone, consistent with clinical guidelines, before therapy is started.
• Refills contingent on monitoring. Ongoing prescriptions require that you remain current with follow-up laboratory testing and check-in visits (typically around 3 months after starting therapy and approximately every 6 months once stable). If monitoring lapses, refills will be paused until it is completed.
• No guarantee of prescription. Completing intake, paying fees, or attending a visit does not guarantee that testosterone or any medication will be prescribed. Prescribing decisions are clinical judgments made solely by your provider.
• Prescription monitoring program review. You consent to your provider reviewing your record in the Texas Prescription Monitoring Program (PMP), as required for controlled-substance prescribing.
• Secure storage and lawful use. You agree to store medication securely, use it only as prescribed, and never share, sell, or transfer it. Diversion of a controlled substance is a crime and results in immediate discharge from the practice.

4. Expected benefits

• Access to specialized hormone care without travel or time away from work
• Guideline-based diagnosis and treatment with structured laboratory monitoring
• Convenient scheduling, direct messaging, and medication delivered to your home
• Continuity of care with a single provider who knows your history

5. Risks of telehealth

• Technology can fail: video or audio may disconnect or degrade, which may delay care. If a visit cannot be completed, it will be rescheduled at no additional charge.
• A remote visit does not allow a hands-on physical examination. Your provider may determine that an in-person examination or referral is necessary before or during treatment, and you agree to complete it if so.
• As with any electronic system, security protocols could theoretically fail. We use HIPAA-compliant, encrypted platforms and business associate agreements to protect your information.

6. Risks and side effects of testosterone therapy

Testosterone replacement therapy has real risks. Not all of them occur in all patients, and many are manageable with monitoring — which is why monitoring is mandatory here. Known risks include:

• Erythrocytosis (thickened blood): increased red blood cell count, which can raise the risk of blood clots; this is the most common serious side effect and the reason hematocrit is checked at every monitoring draw
• Fertility suppression: testosterone suppresses sperm production, often profoundly; recovery after stopping is usual but not guaranteed and can take months to years — tell your provider if you may want biological children
• Acne and oily skin
• Fluid retention
• Worsening of existing sleep apnea
• Gynecomastia (breast tissue growth or tenderness)
• Testicular atrophy
• Mood changes, irritability, or aggression
• Changes in cholesterol and lipid levels
• Effects on the prostate: testosterone can stimulate growth of existing prostate cancer, and PSA is monitored where clinically indicated
• Injection-site pain, bruising, or scarring

7. Alternatives to treatment

You are free to decline treatment or pursue alternatives, including: addressing sleep, obesity, medication effects, or other underlying causes of low testosterone; lifestyle and strength-training approaches; medications that stimulate the body’s own production (where appropriate, particularly when fertility is a priority); or no treatment at all. Your provider will discuss alternatives relevant to your situation during your visit.

8. Emergencies

Telehealth is not appropriate for emergencies. If you experience chest pain, difficulty breathing, one-sided weakness, sudden severe leg pain or swelling, thoughts of harming yourself, or any other emergency, call 911 or go to the nearest emergency room immediately. Do not wait for a response through the patient portal.

9. Your rights as a patient

• You may withdraw consent to telehealth and stop treatment at any time.
• You may ask questions about any aspect of your care and receive plain answers.
• You have the right to access your medical records as described in our Privacy Policy & HIPAA Notice.
• You have the right to know the credentials of the clinician treating you and the existence of the practice’s Prescriptive Authority Agreement.
• Declining treatment will not affect your right to future care.

10. Financial policy

Purelivity Wellness is a cash-pay practice and does not participate in or bill any insurance plan, including Medicare and Medicaid. Fees are disclosed before you pay: a one-time onboarding fee of $249 (intake review, both baseline laboratory panels, initial video consultation, and treatment plan) and, if treatment is initiated, a monthly membership of $150 (medication and supplies, follow-up visits, monitoring labs, and direct messaging), cancellable at any time. As a self-pay patient you are entitled to a Good Faith Estimate of expected charges under the federal No Surprises Act; one is provided before onboarding and on request at any time. HSA/FSA cards are typically accepted, but eligibility is determined by your plan administrator.

11. Identity and location verification

Federal and state rules require us to verify who and where you are. You agree to provide government-issued photo identification before your first visit, to be physically located in Texas during every telehealth visit, and to tell us if that changes. Visits conducted while you are outside Texas cannot proceed and will be rescheduled.

12. Complaints

We want to resolve concerns directly — contact us first using the information below. You also have the right to file a complaint with the licensing boards that oversee this practice:

• Texas Board of Nursing (oversees nurse practitioners): www.bon.texas.gov, 1-800-821-3205
• Texas Medical Board (oversees the collaborating physician and telemedicine complaints): www.tmb.state.tx.us, 1-800-201-9353

13. Consent

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