By signing below, I confirm that I am either the patient or the parent or legal guardian of the patient named below, and that I have legal authority to provide consent for the patient’s clinical evaluation. I hereby request and authorize InStride Health and its professional staff to conduct limited clinical evaluations to determine whether the patient’s condition(s) or symptom(s) fall within the scope of services provided by InStride Health.

I understand that: 

• These evaluations are limited, meaning they are intended only to determine appropriateness for care at InStride Health. 
• I will be informed of the results, but the evaluations do not guarantee a diagnosis, any specific outcome, or enrollment in InStride Health. 
• These evaluations do not establish an ongoing provider-patient relationship with InStride Health or its providers. InStride Health and its providers cannot provide ongoing care, treatment, or extended contact beyond the evaluations unless the patient is enrolled in an InStride Health program. 
• If the patient is not enrolled, or if additional medical care is needed beyond InStride Health’s scope, I understand that it is my responsibility to seek care from my regular healthcare provider or another appropriate professional. InStride Health may offer general referrals or community resources but does not coordinate ongoing care for individuals not enrolled in its program. 

CONSENT TO THE USE OF TELEHEALTH

I understand and agree that the evaluations will be conducted via telehealth, which may include phone consultations, video conferencing, and/or the use of other data-sharing technologies. I acknowledge that:

• Telehealth involves electronic communication of health information, both synchronous (live) and asynchronous (stored and shared later). I understand that I will not meet with a provider in person.
• InStride Health providers can only deliver services in states where they are licensed. Patients must be physically located in a state where the provider is licensed to practice at the time of an evaluation. I agree to notify InStride Health if there is a change in location that will impact this legal requirement.
• While InStride Health takes reasonable precautions to ensure the security of its telehealth services, I understand that telehealth carries risks including, but not limited to, potential technical failures, unauthorized interception of data, and/or unauthorized access to stored medical information. If technical issues prevent an adequate evaluation, InStride Health providers may discontinue a telehealth visit.

By signing below, I acknowledge that I have read and understand this consent form, and I voluntarily agree to the evaluations under the conditions stated above. I agree that my electronic signature is the legal equivalent of my handwritten signature and that by signing electronically, I intend to be bound by this agreement.