Patient Informed Consent for Asynchronous Telehealth Services

Effective Date: May 1, 2026  ·  Operated by Manavjeet Sidhu, MD, A Professional Corporation

Please read this document carefully before using NoteForWork.com. By submitting your intake form and using our services, you confirm that you have read, understood, and agreed to this consent.

1. Nature of the Service

NoteForWork.com provides asynchronous (store-and-forward) telehealth services for minor illness documentation. This means:

• You complete a written intake questionnaire describing your symptoms.
• A licensed physician reviews your written responses and makes an independent clinical determination.
• No real-time video call, phone call, or in-person visit is involved.
• This service is limited to the documentation of minor, self-limiting illnesses for work or school absence purposes.

2. Scope and Limitations

This service is NOT intended for and cannot be used for:

• Emergency medical care or acute illness requiring in-person evaluation.
• Diagnosis or treatment of serious, complex, or chronic medical conditions.
• Prescribing medications.
• Providing specialist referrals or ongoing medical management.
• Any condition involving chest pain, difficulty breathing, severe abdominal pain, altered consciousness, or any symptom that may indicate a medical emergency.

3. Physician-Patient Relationship

By submitting your intake form, a limited telehealth physician-patient relationship is established between you and the reviewing physician for the sole purpose of evaluating your eligibility for work or school absence documentation. This relationship is limited in scope and does not constitute ongoing primary care or specialist care.

4. No Guarantee of Documentation

Submission of an intake form does not guarantee issuance of a physician-signed note. The reviewing physician exercises independent clinical judgment. If your symptoms or clinical presentation do not meet criteria for documentation, your request will be declined and you will not be charged. Reasons for declination may include but are not limited to:

• Symptoms suggesting a condition requiring in-person evaluation.
• Symptoms that have persisted beyond 7 days.
• Worsening symptoms over the preceding 24 hours.
• Presence of any red flag symptom as identified in the intake form.
• Age under 6 years.

5. Accuracy of Information

You agree to provide accurate and complete information on your intake form. Providing false or misleading information to obtain medical documentation is a violation of these terms and may constitute fraud. The physician's determination is based entirely on the information you provide. You bear full responsibility for the accuracy of your intake responses.

6. Employer Acceptance

NoteForWork.com cannot guarantee that your employer, school, or any third party will accept the documentation provided. Employer policies regarding medical documentation vary. It is your responsibility to confirm your employer's documentation requirements before submitting a request.

7. Telehealth-Specific Acknowledgments

You acknowledge and understand that:

• Asynchronous telehealth does not allow for physical examination, and the physician's assessment is based solely on your written self-report.
• Telehealth services may not be appropriate for all medical situations.
• Technical failures including internet outages or platform errors may delay or interrupt service delivery.
• Your documentation will be delivered electronically to the email address you provide.

8. Privacy and Health Information

Your health information is protected under the Health Insurance Portability and Accountability Act (HIPAA). Please review our Notice of Privacy Practices for a complete description of how we collect, use, and protect your health information.

9. Right to Withdraw Consent

You may withdraw this consent at any time by contacting us at ceo@noteforwork.com. Withdrawal of consent will prevent future use of the service but will not affect services already rendered.

10. Governing Law

This consent is governed by the laws of the State of California. Any disputes arising from your use of this service shall be resolved in accordance with California law.

By Proceeding You Confirm That:

• You are 18 years of age or older, or the parent/legal guardian of the patient.
• You have read and understood this consent in its entirety.
• You agree to the terms described above.
• You consent to the limited telehealth evaluation described herein.

NoteForWork.com  ·  ceo@noteforwork.com  ·  Effective May 1, 2026