Telehealth Consent Form

Welcome to Glowform.

Before proceeding with your assessment, consultation, or order request, please read and acknowledge this Telehealth Consent Form. This explains the nature of Glowform’s telehealth-supported process, the role of licensed physicians, potential risks and side effects, and how your personal and medical information may be collected, processed, and used.

1. Nature and Purpose of the Service

Glowform provides access to a telehealth-supported process for health, wellness, and treatment-related concerns. Through our platform, you may be asked to complete an online health assessment, provide relevant medical information, and participate in a consultation or medical review with a licensed physician.

Glowform helps facilitate the collection of information, coordination of medical review, communication with licensed physicians, order request processing, customer support, and coordination with relevant service providers where applicable.

Glowform does not independently diagnose medical conditions, prescribe medication, or determine whether any treatment is appropriate for you. Any medical assessment, advice, prescription, treatment decision, or recommendation will be made by a licensed physician based on the information you provide.

Submission of an assessment or order request does not guarantee approval, prescription, or fulfillment. Any prescription-only treatment will only proceed if a licensed physician determines that it is medically appropriate.

2. Limitations of Telehealth

You understand that telehealth involves the remote review of your medical information and may not include a physical examination. Because of this, there may be limitations compared to an in-person medical consultation.

You agree to provide accurate, complete, and updated information about your health, medical history, current medications, allergies, existing conditions, and any other relevant details. Incomplete or inaccurate information may affect the physician’s ability to assess your suitability for any treatment.

Glowform’s telehealth-supported process is not intended for medical emergencies. If you experience severe symptoms, allergic reactions, chest pain, difficulty breathing, fainting, severe abdominal pain, or any urgent medical concern, you should seek immediate medical attention or go to the nearest emergency facility.

3. Acknowledgment of Medical Risks and Side Effects

All treatments, medications, and wellness-related products may carry potential risks, side effects, contraindications, or interactions. These may vary depending on the specific treatment, your medical history, other medications you are taking, and your individual response.

Possible risks may include, but are not limited to, allergic reactions, headache, nausea, vomiting, stomach discomfort, dizziness, site reactions, changes in appetite, or interactions with other medications or medical conditions.

You are encouraged to raise any concerns with the licensed physician during your consultation or medical review before starting any treatment. You agree to follow the physician’s instructions, safety guidance, and any recommended monitoring. You also agree to inform the physician or Glowform support if you experience concerning side effects or if your medical condition changes.

4. Role of the Licensed Physician

Medical evaluations, treatment decisions, and prescriptions, where applicable, are conducted by licensed physicians. The physician will review the information you submit and determine whether any treatment or prescription is appropriate for you.

You understand that the final decision to approve, decline, adjust, or discontinue any treatment rests with the licensed physician. Glowform may only help coordinate the next steps after the required medical review has been completed.

If the physician determines that a treatment is not suitable for you, your request may be declined, placed on hold pending further clearance, or cancelled. Where payment has already been made, applicable refund procedures may apply.

5. Coordination with Service Providers

Where applicable, Glowform may coordinate with third-party service providers, including licensed physicians, pharmacies, fulfillment partners, payment processors, logistics providers, and customer support providers, for the purpose of facilitating the telehealth-supported process.

Glowform’s role is limited to platform support, coordination, communication, order request processing, and related administrative services. Any prescription, medical clearance, or treatment decision remains the responsibility of the licensed physician.

6. Consent for Collection, Processing, and Storage of Personal and Medical Data

To facilitate telehealth and related services, Glowform may collect, process, and store your personal and medical information, including but not limited to your name, contact details, delivery details, health assessment responses, medical history, consultation details, prescriptions, and order request information.

This information may be used to evaluate your suitability for medical review, facilitate physician consultations, coordinate service providers, process order requests, provide customer support, comply with legal and regulatory requirements, and improve our services.

Glowform handles personal information in accordance with applicable data privacy laws, including the Philippine Data Privacy Act of 2012. Your information may be shared with licensed physicians, pharmacies, fulfillment partners, payment processors, logistics providers, and other trusted service providers only as necessary to facilitate the services.

By proceeding, you authorize Glowform to collect, use, process, store, and share your personal and medical information for these purposes, subject to our Privacy Policy.

7. Patient Responsibilities

By using Glowform’s services, you agree to:

  • Provide accurate and complete personal and medical information;

  • Disclose current medications, allergies, medical conditions, and relevant health history;

  • Follow the physician’s instructions and treatment guidance;

  • Read any instructions or safety information provided;

  • Contact the physician or Glowform support if you have questions or experience side effects;

  • Seek urgent medical care when necessary; and

  • Not share any prescribed treatment with any other person.

Acknowledgment and Consent

By checking the box and proceeding with your assessment, consultation, or order request, you confirm that:

  • You have read and understood this Telehealth Consent Form;

  • You consent to participate in Glowform’s telehealth-supported process;

  • You understand that Glowform facilitates access to medical review but does not independently diagnose, prescribe, or make treatment decisions;

  • You understand that a licensed physician will evaluate your information and determine whether treatment is appropriate;

  • You understand that prescriptions will only be issued if medically appropriate;

  • You acknowledge the potential risks, side effects, and limitations of telehealth and treatment;

  • You authorize the collection, processing, storage, and sharing of your personal and medical information as described above and in Glowform’s Privacy Policy;

  • You agree to provide accurate information and follow the physician’s instructions; and

  • You understand that Glowform’s services are not for medical emergencies.