- Community Clinic (CC) staff has explained to me how telehealth communication will be used in order to connect with a homeopath at CC. The telehealth appointments may be conducted by videoconferencing, video images, still images, or by telephone conference. I understand that this appointment will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room.
- I understand there are possible risks to this technology, including interruptions, and technical difficulties. I understand that the CC homeopath or I can discontinue the telehealth appointment if it is felt that the videoconferencing connections are not adequate for the situation. I also understand that I can discontinue the telehealth appointment at any time.
- I understand my health care information may be shared with other CC staff for consultation, scheduling, and billing purposes. Others may also be present during the appointment, other than my homeopath. The above mentioned people will all maintain the confidentiality of the information shared during my appointment. I further understand that I will be informed of their presence during the consultation and thus will have the right to request the following: (1) omit specific details of my medical/physical consultation that are personally sensitive to me; (2) ask others attending my consultation to leave the telehealth session; and/or (3) terminate the telehealth appointment at any time.
- To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session.
- I understand that all electronic medical communications carry some level of privacy risk for the security of my health information. I understand that the CC staff will use good faith efforts to protect the privacy of my health information and to minimize these risks.
- I understand that taking a homeopathic product does not forego the continuation of my conventional medical treatment(s).
- I understand that this consultation may directly benefit my health care by providing me with services otherwise not available. However, results cannot be guaranteed or assured.
- I understand that any information about me obtained as a result of this consultation will be kept confidential. However, my anonymous metrics, treatment of, and results may be entered into a database for educational study.
- I understand the Community Clinic is NOT an emergency service. In the event of an emergency, I will use a phone to call 9-1-1and/or other appropriate emergency contacts.
- I understand that participation in this telemedicine consultation is voluntary and I have been given the opportunity to ask questions and I have received understandable answers.
I willingly consent to participate in this consultation.