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CONSENT FOR ONLINE TELECONSULTATION
Telemedicine is defined as the practice of medicine over a distance in which interventions, diagnostic or treatment decisions and recommendations are based on data, documents, and other information transmitted thru telecommunications system.
This also refers to the practice of medicine by means of electronic and telecommunications technologies such as phone call, chat or short messaging service (SMS), audio- and video-conferencing to deliver healthcare at a distance between a patient at an originating site, and a physician at a distant site.
There is integration of telecommunication systems into the practice of protecting and promoting health. At FitMD Medical Clinic, telemedicine appointments may be conducted by videoconferencing or by telephone conference.
I understand that this appointment will not be the same as a direct in-person patient doctor visit or face-to-face consultation due to the fact that I will not be in the same room as my physician. I understand that I may be asked to share laboratory results, imaging, and other documents about my condition if needed during the consultation.
I understand that the FitMD Medical Clinic will utilize zoom online technology to connect me with a physician on my scheduled appointment. I understand that the medical advice, evaluation, impression, diagnosis, treatment, instructions, and prescriptions made by the physician are solely on the basis of patient history and information shared. I hold the medical clinic and physician free from any liability arising from such medical advice, evaluation, impression, diagnosis, treatment, instructions, or prescriptions.
I understand and agree that my doctor can discontinue the telemedicine consultation if it is felt that the video-conference connections are not adequate for the situation, and/or continuation thereof may not be to my best interest. Likewise, I understand that there is no guarantee that this telemedicine consultation will eliminate the need for me to see a doctor in person.
Accordingly, I shall not hold my doctor, the medical clinic and the medical staff liable for any incomplete or inadequate treatment/management and/or misdiagnosis if the same was a result of my having withheld any material information or due to inherent limitations of this telemedicine consultation, and other unforeseen and unavoidable circumstances.
By electronically signing this form, I understand the following:
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
- I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
- I understand that it is my duty to inform my doctor of any previous in-person or electronic interactions regarding my care that I may have with other healthcare providers.
- I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.