This practice provides medical care through telehealth — the delivery of health-care services using electronic communications between a patient and a licensed provider who are not in the same location. Care may be delivered asynchronously (for example, through a secure health questionnaire the provider reviews) rather than by live video. Please read and accept this consent before receiving services.
Benefits. Telehealth can make care more convenient, discreet, and affordable, and lets you receive care without an in-person visit.
Risks and limitations. The information you provide may be insufficient for the provider to make a diagnosis or prescribe safely, in which case you may be directed to in-person care. Without a physical examination, some conditions cannot be diagnosed or treated by telehealth, and a serious condition could be missed or delayed. Electronic transmission carries a risk of technical failure or, despite safeguards, unauthorized disclosure. Regulatory requirements may limit your treatment options.
By accepting, you acknowledge and agree that:
- You have read this consent and understand the benefits, risks, and limitations of telehealth.
- You give informed consent to receive care by telehealth from the independent licensed providers affiliated with this practice.
- No specific result or cure is guaranteed; your condition may not improve and could worsen.
- You will answer all health and history questions honestly and completely and keep the provider updated on changes; withholding or misstating information to obtain treatment can cause serious harm.
- The provider may determine, in their professional judgment, that your condition is not suitable for telehealth and that you must seek in-person or alternative care.
- Telehealth does not replace your relationship with your existing health-care providers.
- You cannot obtain emergency care through this service; call 911 for emergencies.
- Your information will be handled as described in the Privacy Policy and applicable Notice of Privacy Practices. You may have your telehealth record sent to your other health-care providers by contacting us with your request and the provider’s name, address, and phone number.
- A technical failure may result in loss of information or interruption of your online visit; in addition to the disclaimers in the Terms, you agree to hold the practice and platform harmless for loss of information or delay in care resulting from a technical failure.
- You may withdraw this consent at any time by [CONTACT METHOD]; otherwise it renews with each new telehealth consultation.