I understand that telemedicine is the use of electronic technology for communication for the purpose of providing healthcare services wherever the doctor and the patient are located. I understand that the institution is based in Florida and likewise uses telemedicine to conduct consultation with their patients.

I understand that with the use of telemedicine, the interaction shall be done through real-time audio-video communication. I understand that the laws that protect privacy and confidentiality, as well as the confidentiality of medical information through the Health Insurance Portability and Accountability Act (HIPPA)also apply to telemedicine.

I understand that I will be responsible for any payments or co insurances that apply to my telemedicine visit.I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment; I have the right to access my information and to inspect my medical information that was transmitted through telemedicine; I have the right to privacy where it shall be necessary to seek my consent in order to disclose my information unless those that are permitted by law to disclose without the need of my consent.

I understand any lawsuit airing out of this agreement or service shall be brought to the courts of the state of Florida,to the exclusion of other states. With the pronouncements above: I authorize the Institution to provide me with the irdiagnosis, observations, recommendations regarding my condition through telemedicine. Whenever necessary, I authorize the Institution to consult with other physicians or specialists whom they believe to have full knowledge and skills that can address my case. I have read and understood the information provided above, my rights, and obligations regarding telemedicine. I have had the opportunity to ask questions and all of which were answered to my satisfaction. Therefore, I hereby give my consent to the use of telemedicine for medical care.

I   *   aged   *   _ years, residing in   *   , would like to consult with a health care provider at NovaHealth Clinic, LLC over voice/video call. I want this non-emergency teleconsultation as per my personal choice. I am aware that teleconsultation is not equal to face-to-face consultation and its accuracy may be low. I understand the risks and acknowledge that an alternative is to see my regular physician. I know that I have the right to terminate the consultation at any time without stating any reason. I am aware that my voice or video will be recorded for documentation, and I have no objection to that. I am aware that my doctor will keep my information confidential; however, there may be a rare chance of data tampering. I know that I will get an e-prescription only at the provider’s discretion. I’ve been informed of the limitations of the care NovaHealth Clinic,LLC can provide hence, I will not make NovaHealth Clinic, LLC liable for any treatment received as I understand the potential risks, benefits, and alternatives of the proposed treatment. I hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and conditions. By signing below, I certify that I am the legal representative of the participant or that I am the patient, and I am 18 years of age or older, or other wiselegally authorized to consent.