Please read and sign

Consent for care — in person & telehealth

GynJess · 2358 NW Kings Blvd #202, Corvallis, OR 97330
Effective July 27, 2026

This single consent covers both ways you may be seen at GynJess: in person at our clinic in Corvallis, and by telehealth anywhere in Oregon. Sections II and III apply only to telehealth visits; Section IV applies only to in-person visits. Everything else applies to both.

I. Consent to care

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II. Telehealth visits: what to understand

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III. Telehealth: location & platform

Under Oregon Medical Board regulation and state licensure law, the practice of medicine is defined by where the patient is located at the time of service. You must therefore be physically within the state of Oregon during a telehealth visit.

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IV. In-person visits: examinations & procedures

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V. Certification

By signing below, I consent to receive care from GynJess in person and by telehealth, and I certify that I have read, understood, and agree to this consent. I understand I may withdraw this consent at any time in writing, and that doing so will not affect care already provided.

Patient signature

Date

Printed name

Date of birth