Telemedicine Consent Form

Please complete the consent form before your first telemedicine visit. A PDF copy of your signed consent will be emailed to you and to our clinical inbox for records. No protected health information is stored on this website.

Before you begin

✓ Have a valid photo ID ready for your virtual visit. We only see patients located in New Jersey or New York.
✓ Gather your current medication list, known allergies, and recent measurements (weight, blood pressure, labs if available).
✓ Ensure you have a quiet, private space for video visits and a stable internet connection.
✓ For scheduling questions, email info@medlifewellness.com or call (856) 345-0444.

Telemedicine visits are self-pay only. Superbills are available upon request for personal reimbursement.

Need help?

If you have trouble submitting the consent form, contact our support team or visit thetelemedicine overview for additional instructions.

Telemedicine consent & acknowledgement

Full legal name

Email addressPhone number (optional)

Birth date

CityState (telemedicine visits available in New Jersey and New York)

Focus areas for your telemedicine visit

Telemedicine acknowledgementsI understand that all visits are completed via secure telemedicine. I agree to share accurate medical history, current medications, and recent measurements during each session.I acknowledge that Medical Lifestyle and Wellness Services operates on a self-pay basis. I am responsible for all visit fees at the time of service and understand that no insurance claims will be filed on my behalf.I understand that telemedicine appointments are not for emergencies. If I experience a medical emergency, I will call 911 or visit the nearest emergency department immediately.

Signature (type your full name)

By signing electronically, you certify that the information above is accurate and that you consent to receive telemedicine services from Medical Lifestyle and Wellness Services.