Telehealth Informed Consent

Do not use this service if you are experiencing a medical emergency.  If you are in an emergency situation, call 911 or go to your nearest emergency room.

This Telehealth Informed Consent adds to, but does not change, any existing Terms of Use, Privacy Policy, or Notice of Privacy Practices from Virta. Those documents still apply to your care and services.

By using Virta, you agree to consult with your provider(s) virtually only. This is known as telehealth: healthcare delivered through electronic tools when you and your provider aren’t in the same location. This may include:

• Video or phone consultations
• Remote patient monitoring
• Secure messaging 
• Use of data from medical devices, video, or sound recordings
• Sharing of medical records, images, health information, or other data electronically

All medical care through Virta is delivered via telehealth. Our systems are designed to protect your information through advanced security protocols that safeguard data integrity and privacy.

Risks and Benefits

Virta offers services via telecommunications technology (also referred to as “telehealth”). The services provided may also include chart review, remote prescribing, appointment scheduling, refill reminders, health information sharing, and non-clinical services, such as patient education. The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. 

Benefits of telehealth may include:

• Easier access to care from your home 
• More efficient communication with your provider
• Timely care and guidance from a licensed provider

Possible risks may include:

• Technical issues that delay appointments or limit the quality of shared information
• In rare cases, your provider may ask you to reschedule or see an in-person provider if more information is needed.

Clinical Scope and Appropriateness

Participation in Virta is based on information provided at the time of enrollment and throughout participation. While many individuals benefit from Virta, Virta has not been studied under all possible medical conditions, including cancer and other co-occurring health conditions.

If participation in Virta is found to worsen an existing health condition or is determined to be clinically inappropriate, continued participation may be reviewed and may be reconsidered based on clinical judgment.

Medication Safety During Nutrition Changes

Changes in nutrition may affect the safety and effectiveness of certain medications. Participation in Virta may require medication review, adjustment, increased monitoring, or coordination with other prescribing providers.

The following safety considerations may apply, depending on medical history and current medications:

• Contrave: Contrave levels may change with a low-carb/ketogenic diet and increase seizure risk. Take Contrave at least 2 hours away from meals. Notify your prescribing provider before starting Virta.
• Lithium: Lithium levels may change with nutrition changes. More frequent monitoring may be needed. Notify your prescribing provider before starting Virta.
• Warfarin: Anticoagulation (blood clotting) levels may change with nutrition changes, especially early on. More frequent INR testing may be needed. Notify your prescribing provider before starting Virta.
• Thyroid medications: Your thyroid hormone dose may need adjusting while on Virta. Notify your prescribing provider so they can monitor your levels closely.
• Diabetes medications associated with hypoglycemia risk: Some diabetes medications, including insulin and sulfonylureas such as glipizide, glyburide, and glimepiride, can increase the risk of hypoglycemia during nutrition changes.
  
  • To reduce risk:
    
    • Dietary changes should not begin until a start date is established with a Virta provider
    • Medication adjustment recommendations should be followed as directed
    • Signs and symptoms of hypoglycemia (e.g., shakiness, sweating) should be recognized and reported to the Virta care team
    • A source of glucose should be carried at all times
    • Risky activities should be avoided during episodes of hypoglycemia
  • Medication adjustments may result in temporary hyperglycemia and are made for safety reasons.
• SGLT-2 inhibitor medications: Some diabetes medications classified as SGLT-2 inhibitors, including canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, and bexagliflozin, as well as combination medications containing these agents, including Invokamet®, Xigduo®, Synjardy®, Glyxambi®, QTern®, QTernmet®, Segluromet®, Steglujan®, and Trijardy®, may require temporary discontinuation or adjustments prior to dietary changes. This is to reduce the risk of diabetic ketoacidosis.
  
  • If discontinued, alternative prescriptions may be provided as clinically appropriate. Pharmacy contact information may be required to coordinate changes.
  • Medication decisions will be based on review of medical history and clinical judgment. Daily ketone monitoring may be required while taking these medications.
• Possible insulin deficiency:
  
  • Diabetes may be related to underlying insulin deficiency, which is not known to be reversible. Regardless of cause, diabetes may improve with nutritional changes.
  • Consistent biomarker logging (including blood glucose and ketones) is highly recommended throughout your participation with Virta for safety and clinical oversight.

A note about pregnancy & breastfeeding

• If you’re not planning a pregnancy, we recommend using a form of birth control that works for you.
• If you are planning a pregnancy, some medications used for diabetes and blood pressure aren’t recommended during pregnancy (such as ACE inhibitors, statins, and spironolactone).
• If you become pregnant while on Virta, please let us know as soon as possible. Because care needs change during pregnancy and breastfeeding, Virta can’t provide care during that time.

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By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:

1. You consent to receiving Virta’s services via telehealth technologies. You understand that Virta and their providers offer telehealth-based medical services, but that these services do not replace the relationship between your and your primary care doctor and/or endocrinologist. You also understand it is up to a Virta provider to determine whether or not your specific clinical needs are appropriate for Virta services.
2. You understand that federal and state law requires health care providers to protect the privacy and the security of health information. You understand that Virta will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.
3. You understand there is a risk of technical failures during the telehealth encounter beyond the control of Virta. You agree to hold harmless Virta for delays in evaluation or for information lost due to such technical failures.
4. You understand that you have the right to withhold or withdraw your consent to the use of telehealth at any time, without affecting your general right to seek future care or treatment. You may suspend or stop using telehealth services at any time, for any reason or no reason. However, because the services provided by Virta are offered exclusively via telehealth, withdrawing your consent to telehealth will result in the termination of services with Virta. 
5. You understand that if you are experiencing a medical emergency, you will be directed to dial 9-1-1 immediately and that the Virta providers are not able to connect you directly to any local emergency services.
6. You understand that alternatives to telehealth consultation, such as in-person services are available to you, and in choosing to participate in a telehealth consultation, you understand that some parts of the services involving tests may be conducted by individuals at your location, or at a testing facility, at the direction of a Virta provider (e.g., labs or bloodwork).
7. You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.
8. You understand that your healthcare information may be shared with other individuals for scheduling, treatment and billing purposes. 
9. You understand that you will not be prescribed any narcotics, nor is there any guarantee that you will be given a prescription at all. Any prescriptions provided will be issued only if medically appropriate and in accordance with your employer or health plan’s requirements.
10. You understand that participation in Virta may require medication review, adjustment, additional monitoring, or coordination with other prescribing providers to support safety during nutritional changes.
11. You understand that if you participate in a consultation, that you have the right to request a copy of your medical records which will be provided to you at reasonable cost of preparation, shipping and delivery.
12. You understand Virta and its providers reserve the right to deny care for any reason in the reasonable discretion of the provider, including without limitation if, in the professional judgment of your provider, the provision of the services,including when provided via telehealth, is not medically or ethically appropriate; and for illegal conduct (such as falsifying information to obtain prescription drugs), abusive and threatening behavior, sharing medications or taking medications prescribed to others, continued non-adherence to your treatment plan or continued refusal to pay for our services. We may terminate your use of our services by sending notice to you at the mail or email address you provided to us or by otherwise contacting you.