- I understand that my dermatology provider recommends engaging in telehealth services with me to provide treatment.
- I understand that telehealth treatment has potential benefits including, but not limited to, easier access to care.
- I understand that telehealth has been found to be effective in treating a wide range of disorders, and there are potential benefits including, but not limited to easier access to care. I understand; however, there is no guarantee that all treatment of all patients will be effective.
- I understand that it is my obligation to notify my dermatology provider of my location at the beginning of each treatment session. If for some reason, I change locations during the session, it is my obligation to notify my dermatology provider of the change in location.
- I understand that it is my obligation to notify my dermatology provider of any other persons in the location, either on or off camera and who can hear or see the session. I understand that I am responsible to ensure privacy at my location. I will notify my dermatology provider at the outset of each session and am aware that confidential information may be discussed.
- I understand that it is my obligation to ensure that any virtual assistant artificial intelligence devices, including but not limited to Alexa or Echo, will be disabled or will not be in the location where information can be heard.
- I agree that I will not record either through audio or video any of the session, unless I notify my dermatology provider and this is agreed upon.
- I understand there are potential risks to using telehealth technology, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption.
- I understand that my dermatology provider is not responsible for any technological problems of which my dermatology provider has no control over. I further understand that my dermatology provider does not guarantee that technology will be available or work as expected.
- I understand that I am responsible for information security on my device, including but not limited to, computer, tablet, or phone, and in my own location.
- I understand that my dermatology provider or I (or, if applicable, my guardian or conservator), can discontinue the telehealth consult/visit if it is determined by either me or my dermatology provider that the video conferencing connections or protections are not adequate for the situation.
- I have had a conversation with my dermatology provider, during which time I have had the opportunity to ask questions concerning services via telehealth. My questions have been answered, and the risks, benefits, and any practical alternatives have been discussed with me.
By signing this document, I acknowledge:
- Pore House is NOT an emergency service. In the event of an emergency, I will use a phone to call 9-1-1 and/or other appropriate emergency contact.
- I recognize my dermatology provider may need to notify emergency personnel in the event he/she feels there is a safety concern, including but not limited to, a risk to self/others or my dermatology provider is concerned that immediate medical attention is needed.
- Though my dermatology provider and I may be in virtual contact through telehealth services, neither Pore House or my dermatology provider provides any medical or emergency or urgent healthcare services or advice. I understand should medical services be required, I will contact my physician. If emergency services are needed, I understand I should call 9-1-1.
- Pore House facilitates telehealth services and this technology platform is not, itself, a source of healthcare, medical advice, or care.
- To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session.
- I understand that either I or my dermatology provider can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me. I understand there may be no other treatment alternative available.
I have read and understand the information provided above regarding telehealth, have discussed it with my dermatology and I hereby give informed consent to the use of telehealth.