CONSENT TO TELEHEALTH DIET DOC
March 10, 2014
Make sure you read all the important information below because we cover:
- When our duty of care begins.
- The benefits and risks of using our service.
- The importance of reading all the information we provide.
- The importance of answering all questions fully and truthfully.
- The risks of accepting our treatment plan.
- The risks to electronic health information.
Only use our service if you’ve read this information and subsequently made an informed decision that our service is right for you. If you have any questions, please send us a message by email email@example.com or call us at 800.581.5038.
Notice for patients nationwide – this service is provided by legal entity Perfect Health Technologies, Inc. a Professional Corporation doing business as Diet Doc (‘Diet Doc’).
NOT FOR EMERGENCIES
I understand that I should never use Diet Doc in a medical or psychiatric emergency. I understand that in an emergency, I should dial 911 or go to an emergency department.
WHEN OUR DUTY OF CARE BEGINS
I understand that Diet Doc doctors (‘the doctor’) will take responsibility for my care only after I have completed and answered all the required health questions and provided a driver’s license number to establish that care is provided to an adult of legal age and the doctor has subsequently reviewed my request for treatment and the health questions that I have completed and any photos and/or information received from a video or telephonic consult, reviewed all my information, and then subsequently determined that I am a good candidate for the telehealth services. I understand that the duty of care does not begin at the point of me answering questions or making payment or starting a video or telephonic consult but at the point at which the doctor accepts the duty of care.
I understand that the doctor has the right to refuse to take responsibility for my care if the doctor makes a professional judgment that I am not a good candidate for this service. I understand that making a request for treatment (by completing patient paperwork from website and making payment) or sending a message does not in and of itself create a duty of care or create a doctor-patient relationship.
I understand no other content in the Website constitutes professional medical advice. Specifically the information provided in our health questions about who we can and cannot treat does not constitute professional medical advice.
I understand that all other content in the Website does not constitute professional medical advice and is instead for information purposes only. Never disregard professional medical advice or delay in seeking it because of something you have read on our Website or general internet searches.
BENEFITS AND RISKS OF USING OUR SERVICE
I understand that by using the service I’m seeking great care that’s convenient and affordable.
I understand that important differences exist between Diet Doc’s model of care and traditional healthcare. Specifically by using Diet Doc, I accept a far greater responsibility to read and understand information throughout the Website about the limitations of Diet Doc’s model of care, the risks of seeking care this way, and the risks and benefits of a proposed treatment plan.
I understand that by using Diet Doc I accept the responsibility to provide full and truthful answers to all questions and, when requested, to provide unaltered photos of me that are taken at the time of using our service. To establish care is for an adult.
I understand that the doctor is unable independently to verify the information and photos I provide and that the doctor will make a professional judgment based on the information and photos I provide.
I understand that by using the service for a telemedical consultation, I won’t have an in person consultation and physical exam that might identify a medical condition that needs further investigation or immediate treatment.
I understand that if I have any questions relating to my care that aren’t urgent, I can call the office and schedule a same-day doctor consultation, or schedule for next business day.
IMPORTANCE OF READING ALL THE INFORMATION WE PROVIDE
I understand the importance of reading the information the doctor provides about adverse events, including the signs and symptoms of serious side effects and common side effects from taking a medicine, as this will ensure that I seek appropriate medical attention in a timely manner.
IMPORTANCE OF ANSWERING ALL QUESTIONS FULLY AND TRUTHFULLY
I understand that by using Diet Doc I seek to enter into a relationship where the doctor relies exclusively upon information and photos that I provide to decide whether or not treatment is safe and appropriate.
I understand that the doctor has no way of verifying the information and photos that I provide and that the doctor will consider information to be accurate, true and complete, including my age, gender and all my answers to health questions, and the photos to be of me, taken at the time of me using the service, and unaltered.
I understand that if I provide information that isn’t true and complete, then I’ll be at greater risk of adverse events from any treatment that the doctor prescribes and I may take a treatment that isn’t necessary, appropriate, or safe.
I understand that if I provide photos that are altered, not of me or not taken at the time of me using the service, then I’ll be at greater risk of adverse events from any treatment that the doctor prescribes and I may take a treatment that isn’t necessary, appropriate, or safe.
I understand that even if I provide information that is true and complete, I’m still at risk of adverse events from any treatment that the doctor prescribes.
I understand that even if I provide photos that are unaltered, of me and taken at the time of using the service, I’m still at risk of adverse events from my treatment that the doctor prescribes.
I understand that by using Diet Doc I’m giving my explicit consent for the doctor to access medication history.
RISKS OF ACCEPTING OUR TREATMENT PLAN
I understand that all the medicines that the doctor may prescribe or recommend, including over the counter medicines and ‘behind the counter’ medicines can cause serious side effects and adverse events that include severe allergic reaction, permanent disability and death.
I understand that it is my responsibility to make an informed decision whether to accept a treatment plan that the doctor proposes after weighing the risks and benefits of the medicine being prescribed, alternative treatment options and the risks and benefits of such alternatives, and the option of not seeking any treatment.
I understand that adverse events can be caused by a number of things, including an allergic reaction, side effects, or interactions between a medicine that the doctor prescribes and any medical conditions I may have, other prescription medicines or other things (e.g., supplements, herbs, over-the-counter medicines, or recreational drugs) I’m taking, and lifestyle choices such as smoking tobacco products or drinking alcohol.
I understand that by using Diet Doc to diagnose and treat erectile dysfunction, the doctor won’t have the opportunity to conduct a detailed physical examination that would be possible if I were to see a doctor in person. Because Diet Doc doctors cannot do a detailed physical examination there is a risk that they may not identify potential physical causes of my condition that they would be able to identify and investigate further if I were to see them in person.
I understand that Diet Doc doctors can order a set of laboratory tests, help me understand the tests results and advise me on next steps.
RISKS TO ELECTRONIC HEALTH INFORMATION
I understand that although Diet Doc implements a wide range of administrative, physical, and technical safeguards to protect my health information and comply with HIPAA, Diet Doc cannot guarantee the privacy and confidentiality of my health information.