Consent to receive services via Telehealth

1. I understand that I am voluntarily engaging in a telehealth/telemedicine consultation with Peak Medical Wellness.

2. I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.

3. While Peak Medical Wellness provides valuable telehealth services, it’s important to note that they are not intended for emergencies. In the event of a critical or urgent medical situation, please use a phone to dial 911, visit the nearest emergency department, or seek care at an urgent care facility.

4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

6. I understand that the alternative to a telehealth consultation is to forgo evaluation and treatment with Peak Medical Wellness and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation.

7. I consent to using telehealth video calls for my Peak Medical Wellness session, and understand that with telehealth, some parts of the physical examination might be limited. If you are receiving care by a provider via video call, certain tests, checking specific body areas, and vital signs may be omitted due to limitations from the video call.

8. If physical examination is required due to the nature of the treatment, I understand that I may need to meet in-person with my provider who will perform all appropriate tests and assessments.

9. To maintain my privacy, I will not share telehealth login information or video conferencing links with anyone unauthorized to attend the appointment.

By signing this form, I certify: That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telehealth. That I have had the opportunity to ask questions and have had them answered to my satisfaction. Required

Privacy and Sharing of Information

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.