By clicking on this box, you consent to being treated via telehealth, and acknowledge and agree as follows:
As a patient, I have the right to be informed about my condition and recommended care. This disclosure is to help me become better informed so I may make the decision to give or withhold my consent as to whether or not to undergo care having had the opportunity to discuss potential benefits and risks involved.
I hereby request and voluntarily consent to virtual examination and holistic care with treatment recommendations that may include a wide range of prescription, and over-the-counter medicines, including hormone replacement therapy, as appropriate (collectively, “Medications”), and vitamins, minerals and herbal remedies (collectively, “Supplements”), as recommended by the licensed medical doctors (M.D.), doctors of osteopathy (D. O.), naturopathic doctors (N.D.) and advanced practice professionals, including nurse practitioners (N.P.), and other appropriately trained and licensed personnel (collectively, “Providers”) working through the practices with which Midi Health, Inc. contracts, including but not limited to Integrative Women’s Care, P.C., Integrative Midlife Care, and Robert G. Aptekar, M.D., Inc. (collectively, the “Practice”), each of which provides services through the Midi Health, Inc. telemedicine platform.
By acknowledging my consent below, I understand and agree to the following:
I acknowledge and agree that at any time throughout my course of treatment, I can request further explanation of any Medications and/or Supplements (collectively, “Therapies”), other methods of treatment, and information about the material risks of the recommended Therapies and other treatments.
I understand that the U.S. Food and Drug Administration does not fully evaluate or approve some Supplements that may be recommended in my care, and that some Medications may be prescribed beyond FDA approved indications. I understand that, as with Medications, Supplements may be associated with side effects in certain sensitive individuals, may interact with certain Medications, or may cause symptoms due to certain pre-existing disease conditions. I do not expect my Providers to be able to anticipate and explain all risks and complications, and I wish to rely on my Providers to exercise judgment in recommending the Therapies and other treatments that my Providers feel at the time, based on the facts then known, are in my best interest. I understand that if I do not undertake the Therapies and other treatments as recommended, I may not get the desired result or may increase chances for an adverse effect.
I understand that it is my responsibility to keep my Providers up-to-date with all of the Medications, Supplements, and other drugs or other remedies that I currently am taking, so that my Providers can make the best informed recommendations for my care.
I have the opportunity to ask questions and discuss with my Providers to my satisfaction about:
● my suspected diagnosis or condition
● the nature, purpose, and potential benefit of the recommended Therapies and other treatments
● the inherent risks, complications, potential hazards, or side effects of the recommended Therapies and other treatments
● the probability or likelihood of success
● reasonable available alternatives to the recommended Therapies and other treatments
● the possible consequences if the recommended Therapies and other treatments are not followed and/or nothing is done
I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from any recommended Therapies or other treatment.
I understand that the Providers of the Practice have been trained in a diverse range of diagnostic and therapeutic options, and offer treatment using evidence-based medicine, while including holistic principles. As such, they may: (a) recommend different tests, (b) interpret standard tests differently, and (c) propose different Therapies and other treatments than my other providers, as many perspectives exist in medicine, and in some cases there may be disagreements among qualified medical experts.
I understand that the Providers will provide services to me via telehealth. Telehealth is a mode of delivering health care services via communication technologies (e.g., internet or cell phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of my care.
With respect to Telehealth services:
● I understand that the Practice offers Telehealth consultations, which are conducted through videoconferencing technology and my Provider will not be present in the room with me.
● I understand there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties. I understand that either my Providers or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit.
● I understand that I could seek an in-office visit for my care elsewhere, and I am choosing to participate in a Telehealth consultation with a Practice Provider.
● To protect the confidentiality of my health information, I agree to undertake my Telehealth consultation in a private location, and I understand that my Provider will similarly be in a private location.
● I understand that my healthcare information may be shared by my Provider with others for treatment, scheduling or billing purposes, and as otherwise set forth in the Practice’s Notice of Privacy Practices.
I understand that my while the Providers may communicate with me through the Practice’s secure portal, I also understand the Providers may contact me directly via any means of communication for which I provide contact information, including but not limited to email and text, and such messages may contain the results, reports, instructions and/or advice related to my diagnosis and/or treatment. I acknowledge that I am responsible for checking and responding to these messages, and I may not hold Midi, the Practice, or any Provider liable for any injury, loss or claims resulting from my failure to read or respond to these messages or comply with the advice or instructions contained in a message from the Practice or any Provider. I acknowledge that email and text may not be secure means of communication, and that any such communications may be subject to intercept or other unwanted access or disclosure. Risks notwithstanding, I consent to the use of unsecure means of communications.
TO THE EXTENT PERMITTED BY LAW, BY SIGNING THIS AGREEMENT, I AGREE THAT MY RIGHT TO TRIAL BY A JURY OR A JUDGE IN A COURT WILL BE BARRED AS TO ANY DISPUTE RELATING TO INJURIES THAT MAY RESULT FROM NEGLIGENCE DURING MY CARE BY THE PRACTICE AND ITS PROVIDERS, AND WILL BE REPLACED BY AN ARBITRATION PROCEDURE.
I FURTHER AGREE THAT ANY CLAIMS THAT MAY ARISE OUT OF MY CARE WILL BE SUBMITTED TO AN ARBITRATOR, RATHER THAN TO A COURT FOR DETERMINATION. THE DECISION OF THE ARBITRATION PANEL WILL BE FINAL.
By accepting this form, I acknowledge I have carefully read, or have had read to me, and understand the above consent. I give my permission and consent to care, including Therapies and other treatments by the Practice and its Providers, as well as the videotaping of my visit, and I am fully aware of what I am signing. I intend this consent form to cover the entire course of care for my present condition and for any future condition(s) for which I seek Therapies or other treatment from the Practice.