I understand that my health professional, Dr. Jorge Minera, M.D. wishes for me to participate as a client in a telemedicine consultation at Comprehensive Medical Weight Loss Solutions.
I understand the following:
1. My health care professional and I will communicate by ineractive video conferencing with health care professionals from Comprehensive Medical Weight Loss Solutions.
2. Digital images of my medical condition will be made and sent to physicans and other health care professionals at Comprehensive Medical Weight Loss Solutions for evaluation and consultation with my health care professional.
3. It is the role of my health care pratictitioner to determine whether or not the condition being diagnosed, type of activitied permitted using telemedicine services, and/or treated appropriate for a telemedicine encounter.
4. Appropriate security measures have been taken with telemedicine services but risks to privacy still exist notwithstanding such measures.
5. My health care professional shall be held harmless for any information lost due to tehcnical difficulties.
By signing this consent, I authorize my health professional to release any relevany medical information, pertaining to my medical condition and medical care to Comprehensive Medical Weight Loss Solutions, its physcians and health care professionals. I also understand that Comprehensive Medical Weight Loss Solutions is not currently accepting insurance and I am liable for my medical bills. I have read this document carefully, and hereby consent to participate in the telemedicine consultation under the terms described above.
By signing below I state that I an 18 year of age or older, or otherwise authorized to consent. I have read or have had explained to me the content of this form and I agree to recieve the care, treatment or services listed in this consent. I have had a chance to ask questions and all of my questions have been answered.