Electronic Signature, Telemedicine & Prescription Refill Authorization
Do not request an electronic visit or online prescription refill for an urgent or emergency medical problem. If you are experiencing a medical emergency, call 911 or go to the nearest emergency room immediately.
By submitting this online prescription refill request and/or requesting a virtual e-visit, I acknowledge and agree to the following:
I am requesting a virtual e-visit and/or online prescription refill review through Feel Ideal 360 with Dr. Angela Straface or another authorized Feel Ideal 360 medical provider.
I understand that submitting this request does not guarantee that a prescription will be prescribed, refilled, continued, or modified. All prescription decisions are made solely at the medical provider’s discretion based on my medical history, current symptoms, medication safety, treatment plan, applicable medical standards, and any information I provide.
I understand that I may be required to complete a medical questionnaire, provide updated health information, complete laboratory testing, schedule a virtual visit, or be seen in person before a prescription refill can be approved.
I certify that all information I provide is accurate, complete, and truthful to the best of my knowledge. I agree to notify Feel Ideal 360 of any changes in my health, medications, allergies, pregnancy status, side effects, adverse reactions, new diagnoses, surgeries, hospitalizations, or other medical conditions before continuing or restarting any medication.
I understand that after reviewing my information, the provider may determine that my request is not appropriate for an online prescription refill or virtual e-visit. In that case, I may be instructed to schedule an in-office visit, seek care from another medical provider, complete additional testing, or seek emergency care.
I understand that a virtual e-visit may involve communication by secure electronic form, patient portal, teleconference, telephone, cellular phone, online chat, or other communication methods permitted under applicable Texas law and clinic policy. I acknowledge that personal health information may be communicated electronically as part of this request.
I understand that telemedicine and online refill requests have limitations because the provider may not be able to perform a full physical examination. As with any medical service, medical advice, or prescription decision, there are potential risks, including the risk of incomplete information, misunderstanding, technical failure, delay in response, or the need for in-person evaluation. I accept these limitations and understand that I should seek urgent or emergency care when appropriate.
I understand that my provider will document the virtual e-visit, refill request, medical decision-making, and related communications in my medical record.
I understand that prescription refill requests and virtual e-visits are reviewed within a defined period of time during normal clinic operations and are not intended for urgent or emergency medical needs.
I acknowledge and agree to Feel Ideal 360’s terms of service, privacy practices, payment policies, cancellation policies, and applicable clinic policies.
I understand that I am paying for the provider’s review of my prescription refill request and/or virtual e-visit, not for a guaranteed prescription. The decision to prescribe, refill, deny, change, or discontinue medication is based solely on the provider’s medical judgment. I understand that fees for online prescription refill requests and/or virtual e-visits are non-refundable once the provider review has begun. If I cancel a telemedicine appointment and request a refund, I understand that a 3% processing fee may apply.
By typing my name below and submitting this form, I acknowledge that my typed name serves as my legal electronic signature and has the same force and effect as my handwritten signature.