WASEF HEALTH
TELEHEALTH INFORMED CONSENT
Effective Date: April 21, 2026
1. Introduction
This Telehealth Informed Consent ("Consent") describes how you, the patient, will receive
medical care from licensed healthcare providers affiliated with Wasef Health, P.C., a New
Jersey professional corporation, together with its affiliated professional entities Wasef Health
CA, P.C. (California), Wasef Health KS, P.A. (Kansas), Wasef Health PR, P.C. (Puerto Rico),
and Wasef Health TX, P.A. (Texas) (collectively, "Wasef Health," "we," "us," or "our") using
telehealth technology. Please read this document carefully. By acknowledging this Consent, you
confirm that you understand and agree to receive telehealth services for your care.
2. Wasef Health's Professional Entities
Wasef Health operates as a multi-jurisdiction professional medical group. Your care is provided
by the Wasef Health entity that is licensed to practice medicine in the state or territory where
you are physically located at the time of your visit. The entities that collectively form Wasef
Health are listed below:
Legal Entity Jurisdiction
Wasef Health, P.C. New Jersey
Wasef Health CA, P.C. California
Wasef Health KS, P.A. Kansas
Wasef Health PR, P.C. Puerto Rico
Wasef Health TX, P.A. Texas
Your Provider will hold an active license in the jurisdiction where you are physically located at
the time of your visit.
3. What Is Telehealth?
Telehealth is the delivery of healthcare services using electronic communication technologies.
Telehealth may include:
• Live two-way audio and video consultations
• Store-and-forward transmission of medical information (for example, photos, medical
history, questionnaires, or laboratory results)
• Asynchronous (non-real-time) messaging and review of your health information
Telehealth services may be provided by physicians, nurse practitioners, physician assistants, or
other licensed clinicians ("Providers") affiliated with Wasef Health.
4. Services May Be Delivered Through Partner Platforms
Wasef Health partners with third-party platforms and technology vendors (including, but not
limited to, OpenLoop Health and its affiliates, and other platform partners) to deliver telehealth
services. These partners may provide the patient intake, video infrastructure, electronic health
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record, prescription routing, payment processing, and patient communication tools used in your
care. Clinical decisions are made solely by your Wasef Health Provider.
5. Expected Benefits
• Improved access to healthcare, including from remote or underserved locations
• Shorter wait times and greater scheduling flexibility
• Reduced travel, time away from work, and exposure to other illnesses
• Continuity of care coordination, where clinically appropriate
6. Potential Risks and Limitations
Although telehealth offers many benefits, there are certain risks and limitations you should
understand:
Incomplete physical examination. Your Provider will not be able to perform a hands-on
physical exam, which may limit the ability to diagnose or treat certain conditions.
Technology failures. Delays, disconnections, poor image or audio quality, or outages may
occur and could affect the quality of your visit.
Data transmission. Despite reasonable safeguards, there is a small risk that electronic
transmissions could be intercepted or accessed without authorization.
Information you provide. The quality of care depends on the accuracy and completeness of
the information you share. Omitting information may affect diagnosis, treatment, or safety.
Clinical limitations. Some conditions cannot be safely managed via telehealth and may require
in-person evaluation, laboratory testing, or imaging. Your Provider may decline to treat, request
further workup, or refer you to in-person care if telehealth is not appropriate.
Prescribing limitations. Your Provider may decline to prescribe certain medications via
telehealth, including controlled substances, based on clinical judgment and applicable law.
7. Alternatives to Telehealth
You have the right to receive care in person from a qualified provider. You may decline
telehealth at any time and pursue in-person care. Declining telehealth will not affect your ability
to seek other medical services.
8. Confidentiality and Privacy
Your health information is protected under the Health Insurance Portability and Accountability
Act ("HIPAA") and applicable state and territorial laws. How we collect, use, and disclose your
protected health information ("PHI") is described in our Notice of Privacy Practices ("NOPP"),
available at https://wasef-health.com and upon request. By acknowledging this Consent, you
acknowledge that:
• Your visit and related clinical information may be stored electronically in a HIPAA-
compliant system operated by Wasef Health or its technology and platform partners
(including, where applicable, OpenLoop Health).
• Your clinical information may be shared with other licensed providers within Wasef
Health, with pharmacies for prescription fulfillment, and with other parties as permitted or
required by law.
• Audio, video, or photo content captured during your visit may be stored in your medical
record to support continuity of care.
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9. Not for Emergencies
Telehealth is not intended for medical emergencies. If you are experiencing a medical
emergency, call 911 or go to the nearest emergency department immediately. Examples of
emergencies include chest pain, difficulty breathing, severe bleeding, signs of stroke, suicidal
thoughts, or any condition you believe is life-threatening.
10. Honest and Complete Information
You agree to provide accurate, current, and complete information about your medical history,
medications, allergies, symptoms, and any other information requested by your Provider.
Providing false or incomplete information may result in unsafe care, denial of services, or
termination of the provider-patient relationship.
11. Prescribing
Prescribing decisions are made by your Provider based on clinical judgment and applicable
federal, state, and territorial laws. Your Provider may:
• Decline to prescribe a requested medication
• Require additional information, laboratory testing, or in-person evaluation before
prescribing
• Decline to prescribe controlled substances via telehealth where not permitted or clinically
appropriate
• Check state Prescription Drug Monitoring Programs (PDMPs) as permitted or required
12. Financial Responsibility
You are responsible for any fees associated with your telehealth visit and any prescribed
medications, laboratory testing, or follow-up services, unless otherwise covered by insurance or
the platform through which you are receiving care. Fees will be disclosed prior to service.
13. Right to Withdraw Consent
You may withdraw this Consent at any time by notifying Wasef Health in writing at
contact@wasef-health.com or at the mailing address below. Withdrawal will not affect the
lawfulness of care provided prior to withdrawal.
14. Provider-Patient Relationship
A provider-patient relationship is established between you and your Wasef Health Provider
through your telehealth visit. This Consent applies to your current visit and to future telehealth
visits with Wasef Health providers unless and until withdrawn.
15. State-Specific Acknowledgments
Certain states and territories impose additional telehealth consent or disclosure requirements.
Where applicable, those requirements are incorporated into this Consent, and by
acknowledging this Consent you agree to comply with any additional state-specific or territorial
attestations presented to you during your visit or intake.
16. Patient Acknowledgment and Consent
By acknowledging this Consent (electronically, by checkbox, by signature, or by proceeding with
a telehealth visit), you confirm that:
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• You have read and understand this document.
• You have had the opportunity to ask questions and receive answers to your satisfaction.
• You are voluntarily consenting to receive telehealth services from Wasef Health.
• You are physically located in the United States or in a United States territory where
Wasef Health is licensed to provide care, at the time of your visit.
• You are 18 years of age or older, or you are the parent or legal guardian of a minor
patient and are providing consent on their behalf.
Patient Name (printed): _______________________________________
Patient Signature / Electronic Acknowledgment:
_______________________________________
Date: _______________________________________
Contact Information
Simone Wasef, Privacy Officer
Wasef Health, P.C.
5260 78th Avenue N, Box 1697, Pinellas Park, FL 33780
Email: contact@wasef-health.com