- I understand that I am voluntarily engaging in a telemedicine consultation done by a “store and forward” route with (MIND & BODY RENEW / A PENNY FOR YOUR THOUGHTS ).
- I understand that I am submitting a health questionnaire that will contain my basic medical history, current symptoms (if any), and goals for treatment that will be reviewed by a licensed medical provider. The medical provider will then approve the desired medical interventions and/or prescriptions being requested after reviewing your submitted information. Your request will be approved pending any contraindications to therapy and you will be notified by email within 12-24 hours. If the medical provider does not approve the interventions and/or prescriptions being requested, you will be notified by email and will be refunded, in full, the purchase price of the skin care prescriptions.
- I understand that the health questionnaire I fill out on this website that will be submitted to the medical provider will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. I understand that this is a convenience and a courtesy provided by (MIND & BODY RENEW / A PENNY FOR YOUR THOUGHTS ).
- I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.
- I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the video conferencing connections are not adequate for the situation.
- I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation (if done via video or phone) that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
- I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with (MIND & BODY RENEW / A PENNY FOR YOUR THOUGHTS ).
- and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation via a “store and forward” route.
- I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through (MIND & BODY RENEW / A PENNY FOR YOUR THOUGHTS ).
- will be limited or not done at all. I understand that I am submitting a health questionnaire that will contain my basic medical history, current symptoms (if any), and goals for treatment.
- Telemedicine services offered through (INSERT LLC NAME) are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.
By signing this form, I certify: (FORM WILL BE SIGNED ELECTRONICALLY IN YOUR EMR)
- That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.
- 12. That I have had the opportunity to ask questions, if desired by emailing (MIND & BODY RENEW / A PENNY FOR YOUR THOUGHTS ).
- through the contact us section, and have had them answered to my satisfaction before submitting the requested information