Step 3 is the final form to fill which requires a signature at the bottom of this page.
Telemedicine: Wellness Education & Podiatry Service Disclosures
Templates to govern all remote sessions—both non‑medical wellness and state‑limited podiatry—with staff and practitioners.
A. Tele‑Wellness Education Disclosure (All Staff)
Applies to any staff-led video/audio/text consultation on general wellness topics.
1. Scope & Role
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Session is strictly wellness education and lifestyle coaching.
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Staff are wellness consultants, energy‑healing coaches, or equivalent; not licensed to diagnose or treat medical conditions.
2. Disclaimers
“The content provided in this session has not been evaluated by the FDA. It is offered as general wellness information only. Always consult a healthcare professional for medical advice.”
3. Membership Requirement
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To receive any proprietary protocols or product recommendations (e.g. LifeWave patches), participants must join the Private Membership Association (PMA).
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The $25 annual fee is waived until first purchase.
4. Assumption of Risk & Release
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Participant assumes all risk from any wellness recommendations.
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Participant releases Stargate Retreat, Stargate Clinic, LifeWave, Inc., and MedPro from liabilities except gross negligence.
5. Recordkeeping
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Staff shall log each session, noting date, participant name, and topics covered.
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Written notes must include acknowledgment of disclaimers.
6. Governing Law
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Tennessee law governs these disclosures and any disputes.
B. Tele‑Podiatry Medical Disclaimer (Licensed Practitioners)
For licensed podiatrists providing remote medical consultations only to Tennessee residents.
1. Licensing Scope
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Practitioner is licensed to practice podiatry in Tennessee only.
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No medical advice, diagnosis, or treatment may be provided to participants outside Tennessee.
2. Telemedicine Consent
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Participant must sign a Telemedicine Consent Form acknowledging:
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Understanding of podiatry session scope and limitations.
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Agreement to comply with follow‑up in‑person care if needed.
3. Disclaimers
“This session is a podiatric medical consultation under Tennessee law. If you are located outside Tennessee, this consultation is for general foot health education only and does not constitute medical care in your jurisdiction.”
4. Privacy & HIPAA
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All tele‑podiatry sessions use secure, HIPAA‑compliant platforms.
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Participants consent to the use of telehealth technology and understand privacy measures.
5. Emergency Protocol
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Practitioner will advise immediate in‑person care or emergency services if required; telehealth is not for emergencies.
6. Fees & Billing
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Telemedicine session fees are as published; insurance billing limited to Tennessee regulations.
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Participant responsible for co‑pays or fees if not covered.
7. Recordkeeping & Documentation
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Practitioner will document findings and plan in the patient’s medical record.
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A summary is sent to the participant’s designated primary care or in‑person podiatrist as authorized.
8. Governing Law & Dispute Resolution
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Tennessee law applies; disputes by binding arbitration in Knoxville under AAA rules.
C. Combined Telemedicine Access & Consent Form
Telemedicine Access & Consent
By participating in this telemedicine session, I certify that I have carefully read and understand the disclosures provided above for both Wellness Education and Tele-Podiatry services. I expressly agree to the following terms:
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Scope of Service: I understand whether I receive Wellness Education or Tele-Podiatry, the session remains bound by the respective scope and disclaimers:
• Wellness Education sessions are for general lifestyle and energy-healing guidance only, not medical diagnosis or treatment.
• Tele-Podiatry sessions are licensed medical consultations limited to Tennessee residents.
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Membership Requirement: I acknowledge that full access to proprietary protocols and product recommendations (e.g., LifeWave patches) requires membership in the Private Membership Association (PMA). I accept that the standard $25 annual PMA fee is waived until my first purchase, but membership enrollment is mandatory prior to any product distribution or in-depth protocol.
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FDA and Professional Disclaimer: I acknowledge that any statements about therapeutic benefits have not been evaluated by the FDA and reflect the professional wellness opinions of the presenter, not corporate claims. Results may vary.
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Privacy and Recordkeeping: I consent to secure, HIPAA-compliant technology for any medical session and understand that my sessions will be logged and documented by the presenter for recordkeeping and follow-up purposes.
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Assumption of Risk and Release: I voluntarily assume all risks associated with the recommendations provided. I hereby waive and release Stargate Retreat, LLC; Stargate Clinic; LifeWave, Inc.; and MedPro Group, Inc., from any and all liability for claims, damages, or injuries arising from my participation, except in cases of gross negligence or willful misconduct.
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Governing Law and Dispute Resolution: I agree that this consent is governed by Tennessee law, and any dispute will be resolved by binding arbitration in Knoxville, Tennessee, under AAA rules.
7. Additional Disclosures & Statements
Additional
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Technology Failure Disclaimer
“If video or audio transmission is disrupted or you lose connection, we will attempt to re-establish contact. If we cannot, you agree to follow up by phone or reschedule your session.”
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Emergency & After-Hours Protocol
“This platform is not monitored 24/7. If you experience an urgent or life-threatening issue, please call 911 or go to your nearest emergency department.”
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Prescription Policy (for medical telemedicine only)
“Medications will only be prescribed in compliance with Tennessee telemedicine law; prescriptions cannot be issued for controlled substances via this platform.”
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Identity Verification
“By proceeding, you consent to verify your identity (e.g., showing your driver’s license on camera) to ensure compliance with licensure requirements.”
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Data Security & Recording
“We may record sessions for clinical documentation. All recordings are stored securely and only accessed by authorized personnel. You may opt out of recording by notifying us in advance.”
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Insurance & Billing Notice
“If you plan to bill insurance, please confirm coverage for telemedicine under your plan. Any uncovered fees are your responsibility.”
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Cross-State Practice Disclaimer
“Our podiatry license only covers Tennessee. Any advice we discuss for out-of-state participants is purely educational.”
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No-Guarantee Statement
“While we aim to help you, we cannot guarantee specific outcomes or results.”
“This session is provided solely as a member benefit of the Stargate Clinic Private Membership Association. No medical advice, diagnosis, or treatment will be provided. All information is for general wellness education and is not a substitute for professional medical care. For any health concerns, please consult a licensed provider in your home state.”