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Telehealth Informed Consent

I understand that my health and wellness provider, Revival Health Inc, wishes me to have a telehealth consultation.

This means that through an interactive video connection, I will be able to consult with the above-named provider about my health and wellness concerns. My provider has explained to me how telehealth will be used to do such consultations and how else we will use telehealth to connect while working together, using the Flex telehealth platform.

I understand there are potential risks with this technology:

  • The video connection may not work or it may stop working during the consultation.

  • The video picture or information transmitted may not be clear enough to be useful for the consultation.


The benefits of a telehealth consultation are:

  • I do not need to travel to the consult location.

  • I have access to a specialist through this consultation.

I also understand other individuals involved in my treatment and medications may need to use the Flex telehealth platform and that they will take reasonable steps to maintain confidentiality of the information obtained.

I have read this document and understand the risk and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby consent to participate in telehealth sessions under the conditions described in this document.

Changes to This Statement 
The Company reserves the right to change this Policy from time to time. For example, when there are changes in our services, changes in our data protection practices, or changes in the law. When changes to this Policy are significant, we will inform you. You may receive a notice by sending an email to the primary email address specified in your account, by placing a prominent notice on our Revival Health Inc, and/or by updating any Telehealth Informed Consent information page.
Contact Information 
The Company welcomes your questions or comments regarding this Policy. If you believe that the Company has not adhered to this Policy, please contact the Company at: 
Revival Health Inc 
1601 N Sepulveda Blvd. #103 
Manhattan Beach, California 90266 
Email Address: 
Phone Number: 
Effective as of February 23, 2024 

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