1. I understand that I am voluntarily engaging in a telemedicine consultation done by a “store and forward” route with The Hybrid Clinic, LLC. 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.
2. 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 The Hybrid Clinic, LLC.
3. 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.
4. 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.
5. 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.
6. I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with The Hybrid Clinic, LLC 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.
7. I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through The Hybrid Clinic, LLC 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.
8. Telemedicine services offered through The Hybrid Clinic, LLC 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:
That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.
That I have had the opportunity to ask questions, if desired by emailing The Hybrid Clinic, LLC through the contact us section, and have had them answered to my satisfaction before submitting the requested information