TELEHEALTH CONSENT FORM
This Telehealth Consent is an informed consent that you will be deemed to have agreed to if you proceed to use the telehealth services facilitated by iBeauty.com
PURPOSE AND DEFINITIONS: Please note, the purpose of this Telehealth Consent Form (hereinafter referred to as the “Consent”) is to provide you with important information about telehealth and to obtain your informed and express consent to the use of telehealth in the delivery of healthcare services to you by medical professionals (physicians, physician assistants, or nurse practitioners) (hereinafter collectively referred to as the “Providers”) using the online platform operated by ibeauty.com, and/or its contracted third party service providers (hereinafter referred to as the “Service”). In this form, you are referred to as “you” or “your” or “user” or “users” or “patient(s)”.
Please read this Telehealth Consent carefully. If you do not accept the terms mentioned here or if you do not want to provide your consent, then your sole remedy is not to use the telehealth services.
By accessing or using our website in any way, or by placing an order for any of our products, or by clicking on a button or taking similar action, or by seeking a medical consultation to signify your affirmative acceptance of this Telehealth Consent, you hereby represent that:
- You have read, understood, and are willfully consenting to this Telehealth Consent form.
- You are of sound mind, at least 18 (eighteen) years in age (or of such age of majority as prescribed by the applicable law prevailing in your jurisdiction), and otherwise competent to accept this Telehealth Consent. In case you are under the age of 18 years, but above the age of 13 years, then your parent/legal guardian must provide the consent on your behalf. Children under 13 years are not allowed to use our services even if a parent or legal guardian would be willing to provide consent on their behalf.
- YOU UNDERSTAND IF YOU HAVE A MEDICAL EMERGENCY, YOU WILL SEEK IN-PERSON EMERGENCY CARE IMMEDIATELY OR WILL DIAL 911. THE SERVICE IS NOT APPROPRIATE FOR ALL MEDICAL CONDITIONS OR CONCERNS.
- What is telehealth?
Using Telehealth, you can talk to a Provider from any place, including your home. You don’t go to a clinic or hospital. Telehealth involves the delivery of health care or mental health services using electronic communications between a healthcare or mental health provider/professional and a patient who are not in the same physical location. Please note that while telehealth may offer certain benefits, there are also potential downsides and risks associated with its use. TELEHEALTH SERVICES ARE NOT A SUBSTITUTE FOR IN-PERSON CARE IN ALL CASES.
- How do I use telehealth?
- You talk to your provider by phone, computer, or tablet.
- Sometimes, you use video so you and your provider can see each other.
- You are responsible for arranging the necessary means (such as computer/laptop or phone device with an active internet connection) and its associated fees (such as internet connection fee) for connecting with the healthcare provide or mental heath professional.
- What can I expect?
The Telehealth services may include (without limitation) chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education and counseling. The information that you provide may be used for diagnosis, therapy, follow-up, counseling, and/or patient education, and may include one or more of the following: a) electronic transmission of medical records, photo images, personal health information or other data between a patient and a provider, b) health records and test results c) communications using digital means between a patient and a healthcare/mental healthcare provider, d) live two-way audio and video, e) output data from medical devices and sound and video files, etc.
- How does telehealth help me?
- You don’t have to go to a clinic or hospital to see a provider or mental health expert
- You won’t risk getting sick from other people to the extent it results with physical interactions
- It will save time and commute
- Flexible consultation timings
- Increased convenience
- Can telehealth be bad for me?
- There may be interruptions and disconnections due to technical issues, network errors, or bugs.
- You and your provider won’t be in the same room, so it may feel different than an office visit.
- Your provider may make a mistake because they cannot examine you as closely as at an office visit.
- Your provider may decide you still need an office visit.
- Technical problems may interrupt or stop your visit before you are done.
- Security protocols could fail, causing a breach of the privacy of personal health information.
- In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
- Will my diagnostic test results be 100% accurate?
Certain healthcare services provided to you by the Providers via the Service may require that you complete an at-home diagnostic test. Please note, iBeauty.com does not provide any of the diagnostic tests directly. These diagnostic tests are provided by third-party laboratories, and neither iBeauty.com, its owners, directors, officers, affiliates, and its subsidiaries (collectively, “iBeauty.com”), nor any of the Provider(s) can guarantee the accuracy or reliability or completeness of these tests. You should be aware that these laboratory tests are not 100% accurate, and can provide false negative, false positive, or inconclusive results that could impact the Provider’s ability to correctly diagnose or treat your medical conditions. While using the Services, and taking such diagnostic tests, you hereby acknowledge that you are aware of all these risks.
- How will my privacy and security be protected?
- Please note, the electronic systems that are used in the Service will incorporate the required network and software security protocols in order to protect the privacy and security of your information and will include measures to safeguard data against intentional or unintentional corruption or breach.
- The use of the Service may include email communications to and from you that may include your protected health information. You hereby understand and acknowledge that iBeauty.com does not and cannot guarantee the security or privacy of the Services you use to receive communications. Although small, but there still is a chance that someone could use technology to hear or see your telehealth visit. No information on the internet is 100% secure, and by using the Services, you hereby acknowledge such risk.
- What are my alternatives if I do not want to use a telehealth service?
Please note, telehealth is not mandatory, and alternative methods of care may be available to you, such as in-person services, and you may choose an alternative at any time. Always discuss alternative options with your healthcare provider or mental expert. If you are experiencing a life-threatening situation such as contemplating suicide, call 911 or the 988 Suicide and Crisis Lifeline at 988.
- What if I try telehealth and don’t like it?
- You can stop using telehealth any time and disconnect the call.
- You may have alternative methods of care may be available to you. Always discuss alternative options with your healthcare provider or mental expert.
- If you want to take your consent back, please contact us at firstname.lastname@example.org
- If you decide to use telehealth again, please email us at email@example.com
- How much does a telehealth visit cost?
A telehealth consultation booked using our website https://ibeauty.com/ comes without any additional charge.
- Do I have to sign this document?
No. Your access to our website, and complete an order for any product will be deemed as an implied consent. If you do not wish to give us your consent, you are free to not use our services.
- What does it mean if I consent to this document?
If you provide us with your consent to this document, you agree that:
- You have read, understood, agreed, and consented to all the information mentioned in this document.
- We have answered all your questions. If you have any additional question, please reach out to us at firstname.lastname@example.org
- You have weighed all pros and cons of using the telehealth consultation service, and have decided to use it willingly.
- You want a telehealth consultation service.
- Acknowledgment and Undertaking provided by you
BY SUBMITTING YOUR ORDER OR TAKING SIMILAR ACTION TO SIGNIFY YOUR AFFIRMATIVE ACCEPTANCE OF THIS TELEHEALTH CONSENT, YOU ARE ACKNOWLEDGING AND AGREEING TO THE FOLLOWING:
I am availing the healthcare and mental health services which will be provided to me by the Providers via the Service through the means of telehealth. I’ve understood what telehealth is, what its pros and limitations are, and what I can expect out of it. In some cases, my treating Provider may not be a physician, but rather be a nurse practitioner or physician assistant, and I agree to be treated by such non-physician providers (as the case may be).
I am aware that the technology utilized in providing care, such as the Service, may have flaws that may affect its performance and result in errors, incorrect records, data, or content. This could potentially harm the precision, accuracy, and effectiveness of the medical care I receive from Providers.
I also understand that certain diagnostic testing services (such as laboratory products and services offered through the Service) may contain defects which may limit the functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that I receive from the Provider(s).
Telehealth is still at its nascent stage, and is evolving with time. I acknowledge that the delivery of healthcare services via telehealth and the use of telehealth or other technology in my medical care and treatment from Provider(s) may include uses of technology different from those described in this Telehealth Consent Form, or not specifically described in this Telehealth Consent Form. I understand that no potential benefits from the use of telehealth (including without limitation, specific results) can be guaranteed by my Provider(s). I fully acknowledge that my condition may not be cured or improved, and in some cases, may even get worse. There limitations (along with the other ones as described earlier in this Telehealth Consent Form) do exist in telehealth services, and I may not be able to receive diagnosis and/or treatment through telehealth for every condition for which I seek diagnosis and/or treatment. I have had the opportunity to discuss the use of telehealth, including the Service, with my Provider(s), including the pros, limitations, and risks of such use and I am fully aware about the alternatives to the use of telehealth.
My care providers will evaluate my health status and, at their discretion, may decide that it is medically suitable to diagnose and treat my condition using telehealth technology. By utilizing the Service, I acknowledge and accept my provider’s medical evaluation and consent to receive a diagnosis and treatment through telehealth services. I have the right to withdraw my consent to the use of telehealth at any time during the course of Services, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who utilize the Service do not offer in-person treatment. Any withdrawal of my consent will be effective upon receipt of written notice to my Providers, except that such withdrawal will not have any effect on any action taken by iBeauty.com or my Provider(s) in reliance on this Telehealth Consent Form before it received my written notice of withdrawal. Any withdrawal of my consent will not affect any other provision of this Telehealth Consent Form, and I will continue to be bound by this Telehealth Consent Form, and other legal policies of iBeauty.com (as the case may be).
I understand that the use of the Service involves electronic communication to and from me of my personal medical information in connection with the provision of telehealth services, including through email. I understand that it is my duty to provide iBeauty.com and my Provider(s) truthful, accurate and complete information, including all relevant information regarding care that I may have received or may be receiving from healthcare and/or mental health providers.
By continuing to use the Service, I concur with my Provider’s medical assessment and agree to receive a diagnosis and/or treatment via telehealth technology. I understand that each of my Provider(s) may determine in their sole discretion that my condition is not suitable for diagnosis and/or treatment using telehealth technology, including the Service, and that I might need to seek care and treatment from a specialist or other healthcare or mental health provider, outside of such telehealth technology.
I understand that iBeauty.com has a business association with Pharmacy XYZ. I acknowledge that iBeauty.com also has a financial connection with the entity that employs or works with my care provider. I have the option to receive my medical evaluation from a healthcare provider not affiliated with iBeauty.com. The orders I place through iBeauty.com will be fulfilled by its pharmacy partner and delivered directly to me. I am able to obtain my prescription from any pharmacy I choose by reaching out to iBeauty.com’s support team. I will bear the entire cost of using the Service, including any prescriptions I may receive, and I will not attempt to file a claim with Medicare, any federal payor, or any state or private insurance provider. I will hold iBeauty.com indemnified against any such claims.
I understand iBeauty.com does not provide the telehealth services directly, and the same is provided through MD Integrations and their partners. As with any Internet-based communication, I understand that there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Individuals other than the Providers may also be present and have access to my information for the telehealth session. This is so they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies.
Telehealth sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between providers and patient.
I hereby release and hold harmless iBeauty.com, and all its members from any loss of data or information due to technical failures associated with the telehealth service. I understand and agree that the health information I provide at the time of my telehealth service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth consultation, and that such professionals may not have access to my full medical record or information.
I have the right to withhold or withdraw consent to the use of telehealth services at any time and revert back to traditional in-person clinic services.
In case I have any concerns about medical profession, I will contact the Medical Board of my state. In case I will need the contact details of the medical board of my state, I am free to write to email@example.com.
All my questions have been answered to my satisfaction.
LAST UPDATED: Feb 20th, 2023