Medical History Form

Patient Consent to Telemedicine Services
PLEASE READ EACH SECTION CAREFULLY. YOU MAY REQUEST A COPY OF THIS FORM FOR YOUR OWN RECORDS.

Introduction: Telemedicine involves the real-time evaluation, diagnosis, consultation on and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real time. There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand I can ask questions and seek clarification of the procedures and telemedicine technology at any time.

I. Consent for treatment: I voluntarily request Chance to Change and its physicians, nurses, associates, technical assistants and other health care providers as it may deem necessary (collectively “Practice”) to participate in my medical care through the use of telemedicine.

I understand that Practice (i) may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform an in-person physical examination, and (iii) rely on information provided by me. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I further acknowledge my failure to accurately and completely relay information about my medical history, condition and care may adversely impact Practice’s advice, recommendations or decisions about my care. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure.

I understand that if Practice determines in its reasonable professional judgment that telemedicine services will not adequately address my medical needs, I may be required to complete an in-person medical evaluation. I also understand that in the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented, or an in-person medical evaluation may be necessary. Finally, if I experience an urgent matter after a telemedicine session, such as a bad reaction to a treatment, I should alert my treating physician and, in the case of emergencies, dial 911 or go to the nearest hospital emergency department.

II. Release of information: To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of my Personal Information (defined below) to Practice. I understand this disclosure may include my name, address, contact and demographic information, general health status and treatment information, images, individually identifiable health information or protected health information, and other information related to my health or condition (collectively “Personal Information”).

I understand that the disclosure of my Personal Information to Practice, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering.

III. Right to withdraw consent: I understand that I have the right to withdraw my consent to the use of telemedicine in the course of my care at any time.

I have read this Telemedicine Consent in its entirety and agree to be bound by all of its terms and conditions as described above. I acknowledge and agree that I have been allowed to ask any questions and have either (i) declined the opportunity to do so, or (ii) had all my questions answered to my satisfaction.
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Patient Contact Authorization
Patient Contact Authorization PLEASE NOTE THAT CHANCE TO CHANGE DOES NOT DISCLOSE OR SELL ANY PATIENT PROTECTED HEALTH INFORMATION TO ANY THIRD-PARTY BUSINESS OR ONLINE DATABASE.
I, the undersigned, authorize Chance to Change to contact me according to the policies of Practice regarding facets of my care, including requests for information, verification of payment or benefits, and reminders for appointments. I understand and accept that Practice may leave messages on home or cell phone answering systems or send reminder cards by U.S. mail, email, or text message, according to the policies of Practice. If Practice needs to communicate with me regarding my treatment, my preferred method of communication is as follows (check one):

Phone CallEmailText MessageOther
I understand that if I have chosen a phone call as my preferred method of communication, Practice may be required to leave a voicemail for me regarding my treatment. In such an event, Practice should (check one):

Leave a message with detailed information regarding my treatment.Leave a message requesting that I call Practice at a specified phone number.
I understand that, from time to time, Practice may utilize email or text messages to communicate with me both about my treatment and for marketing purposes. I understand that these emails or text messages may include appointment reminders, general health reminders, feedback requests, newsletters and other information relating to Practice. Accordingly, I (check one)

Authorize Practice to email or text me for both treatment and marketing purposes.Authorize Practice to email or text me appointment and health reminders only.Do not authorize Practice to email or text me.
I understand that this authorization will remain in effect until I either submit a subsequent Patient Contact Authorization changing my above stated preferences, or I revoke or withdraw this authorization in writing. To do so, I must send written notice to Practice at c2cmedspa@gmail.com. I acknowledge and agree that Chance to Change and its employees, officers and physicians are released from any legal responsibility of liability for or resulting from the authorized disclosure of my health or billing information.
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Patient Consent for Photography
I, as the patient identified above or the legal representative of such patient (“Patient”), consent to have photographs, videotapes, digital or audio recordings, and/or images of the Patient, and any other method to reproduce or edit such Patient’s likeness or image now known or hereafter developed (collectively, “Photography”), taken by Chance To Change and its staff (collectively “Practice”). I understand that such photography will be recorded to document and assist with the Patient’s care and to assist with Practice’s health care operations.

I understand that the Photography or a portion of the Photography may become part of my medical record and therefore be protected, used and/or disclosed in accordance with Practice’s Notice of Privacy Practices.

I further understand that Practice will own the Photography and I will not receive any payment for such Photography, but that I will be allowed to access or view the Photography or to obtain copies of any portion of the Photography that becomes part of my medical record.

I have read this consent in its entirety and agree to be bound by all its terms and conditions as described above. I acknowledge and agree that I have been given the opportunity to ask any questions and had all

my questions answered to my satisfaction.
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Patient Consent to Treatment
PLEASE READ EACH SECTION CAREFULLY. YOU MAY REQUEST A COPY OF THIS FORM FOR

YOUR OWN RECORDS

I, the undersigned, do hereby request and consent to an evaluation and treatment by Chance to Change and its staff. I wish to rely on the Practice to exercise judgment for my best interest, the below-named patient, during treatment. I will inform the Practice of any sensitive areas or adverse conditions

that I may have had prior to, during, or after treatment. I intend this consent to cover the entire course of treatment.

I understand that any questions I may have regarding the potential side effects, complications, and treatment or treatment area may be directed to the attending Practice staff member during my evaluation and course of treatment.

I understand that the practice of medicine and surgery is not an exact science. I further understand and accept that fees are paid for the performance of medical services only, and not for a guaranteed result.

I acknowledge by my signature below that although a good outcome is expected, and a reasonable effort has been made to establish realistic expectations, there is no warranty, expressed or implied, as to the results that may be obtained.

I request and consent to be transported by Practice staff and/or emergency medical services to a hospital or emergency medical facility in the event of a medical emergency during my treatment at the Practice.
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Medical History Form

Patient Consent to Telemedicine Services

Patient Contact Authorization

Patient Contact Authorization PLEASE NOTE THAT CHANCE TO CHANGE DOES NOT DISCLOSE OR SELL ANY PATIENT PROTECTED HEALTH INFORMATION TO ANY THIRD-PARTY BUSINESS OR ONLINE DATABASE.

Patient Consent for Photography

Patient Consent to Treatment