I understand that my health and wellness provider Dr. Elamir, MD wishes me to have a tele-health consultation.
This means that through an interactive video connection, I will be able to consult with the above named provider about my health and wellness concerns.
I understand there are potential risks with this technology:
- The video connection may not work or it may stop working during the consultation.
- The video picture or information transmitted may not be clear enough to be useful for the consultation.
The benefits of a tele-health consultation are:
- I do not need to travel to the consult location.
- I have access to a specialist through this consultation.
I also understand that they will take reasonable steps to maintain confidentiality of the information obtained. I also understand that this may be recorded for training purposes.
I understand that I am paying for an initial consultation with Dr. Elamir or one of her director of admissions. I will be allowed to reschedule this appointment one time with no additional charge. If I reschedule this appointment I agree to put a credit card on file for my follow up visit. If I do not inform or cancel with Dr. Elamir at least 24 hours prior to my rescheduled appointment I will then be charged an additional $97 that is non-refundable.
I understand all cancellations must be received 24 hours prior to my scheduled appointment, otherwise the paid consultation fee of $97.00 will be forfeited and nonrefundable.
I have read this document and understand the risk and benefits of the tele-health consultation and have had my questions regarding the procedure explained and I hereby consent to participate in tele-health sessions under the conditions described in this document.