ReMend Support Community Consent Form - March 21

Patient Name*

First NameLast Name

Are you currently enrolled with ReMend and meeting with a Mentor?*

Have you previously participated in a ReMend Online Kidney Support Community session?*

Date of Birth*

Date

Email*

example@example.com

Phone Number*

Area CodePhone Number

How did you learn about ReMend?*

Please give us a little background as to why you're interested in participating.*

ReMend Online Kidney Support Community

ReMend is pleased to offer you the opportunity to participate in the ReMend Online Kidney Support Community, which gives dialysis patients the opportunity to discuss common dialysis topics and to share personal experiences and receive moral support.

CONSENT TO PARTICIPATE

The ReMend Online Kidney Support Community is a program offering monthly meetings and provides emotional, psychological, and moral support for ReMend Online Kidney Support Community Members regarding dialysis therapies. The ReMend Online Kidney Support Community does not constitute medical advice or care.
ReMend will determine the length of the sessions (50 minutes) and may end, postpone, or pause any session associated with the ReMend Kidney Community as appropriate.
ReMend Online Kidney Support Community Members participating may include patients and non-patients. I will treat ReMend and all other ReMend Online Kidney Support Community Members with courtesy and respect.
My participation in the ReMend Online Kidney Support Community is entirely voluntary. I can withdraw from the ReMend Online Kidney Support Community or pause or end a Session at any time and for any reason.

Personal Information and Confidentiality

My participation in this ReMend Online Kidney Support Community does not require me to share my personal health information or private information in the Sessions. I will respect other Group Member’s privacy by not repeating confidential information at any other time or place, including on social media.
ReMend will use reasonable efforts to create a safe and secure environment for the ReMend Online Kidney Support Community. ReMend is required by law to report certain information to appropriate authorities. ReMend is not responsible for the actions of Group Members, and I will hold ReMend harmless from the actions of Group Members.

Communication Platform – Zoom

The ReMend Online Kidney Support Community is only available through Zoom. I may participate in the ReMend Online Kidney Support Community from my home or other locations. I authorize ReMend to use the email address listed above to contact me for Sessions, which I will need to access through my personal device (such as a smartphone, computer, or laptop).
Using Zoom services may involve potential risks and benefits. Potential risks include that an unauthorized person may intercept my personal information, or my information may be lost. I can help prevent unauthorized access or disclosure of my Zoom session by using a secure connection, protecting my information, and taking steps to decrease the risk others may hear or see parts of my Zoom session (such as using earphones, using a privacy screen, or speaking softly).
ReMend will try to keep my Zoom visits secure and confidential, to the extent possible in group settings, by following all relevant policies and procedures for Zoom visits. ReMend will attempt to contact me after the ReMend Online Kidney Support Community session if my Zoom connection fails or is interrupted.

Miscellaneous

ReMend Kidney Community Sessions are not appropriate for emergency services. I will call 911 for emergencies.

By signing this form,

I have read and understand the information provided above and my questions were answered to my satisfaction. I understand this consent is effective immediately and I can revoke or withdraw my consent anytime. I understand I have a right to receive a copy of this consent.

Signature*

Please complete to participate.