Telemedicine Consent Agreement

6620 Coyle Avenue, Suite 202, Carmichael, CA 95608
Ph: 916-966-8500; Fax: 916-966-8555
3270 Arena Boulevard, Suite 405, Sacramento, CA 95834
Ph: 916-418-4595; Fax: 916-418-4594
Email: hello@ample.health

TELEMEDICINE CONSENT AGREEMENT

I, the undersigned, confirm that I am physically located in the State of California. At the start of each telemedicine session, I will assist my healthcare provider in completing a check-in process to evaluate the appropriateness of telemedicine services by providing my full name, current location, readiness to proceed, and confirmation that I am in a private, uninterrupted environment. By signing this agreement, I acknowledge and agree to the following:

1. Provider Location and Limitations: My healthcare provider is located in and licensed by the State of California. If I am located outside California, my provider may be unable to prescribe medications or provide assistance during emergencies. For medication needs, I will contact my provider directly. In case of an emergency, I will dial 911 or seek immediate care at the nearest hospital emergency department.


2. Jurisdiction and Governing Law: I agree that any disputes, claims, or legal proceedings arising from or related to the telemedicine services provided by my healthcare provider or their staff will be resolved exclusively in the California state superior courts. This agreement and its interpretation are governed solely by California law.


3. Suitability and Risks: My healthcare provider has determined that telemedicine is appropriate for my medical condition, and I may benefit from its use despite inherent risks and limitations. I understand that while telemedicine may offer expected benefits, no specific results are guaranteed.


4. Alternative Care Options: If my healthcare provider determines that telemedicine is no longer suitable, they may discontinue these services and arrange for an in-person consultation with themselves or refer me to a local healthcare provider for appropriate care.


5. Right to Opt Out: I have the right to revoke my consent to telemedicine services at any time and request in-person healthcare services from my provider.


6. Technology Use and Limitations: I have been informed about the use of electronic communication technologies for telemedicine services. I am comfortable using these technologies to communicate with my provider and understand their limitations, which may necessitate an in-person visit.

By signing below, I confirm that I have read, understood, and agree to the terms of this Telemedicine Consent Agreement.