TELEMEDICINE PROGRAM
Last Updated: 5th June 2024

NEURA HEALTH TELEMEDICINE PROGRAM
PATIENT CONSENT FORM

‍

Introduction

‍

YOU UNDERSTAND THAT BY CHECKING THE “AGREE” BOX FOR THESE TERMS OF USE AND/OR ANY OTHER SUCH FORM OF THE SAME PRESENTED TO YOU FROM TIME TO TIME ON THE SITE YOU ARE AGREEING TO THESE TERMS OF USE AND THAT SUCH ON-GOING ACTIONS IN USING THE SITE CONSTITUTE A LEGAL SIGNATURE AND ON-GOING AGREEMENT TO THESE TERMS OF USE (IN WHATEVER FORM).

‍

For avoidance of any doubt, the terms “On Demand Neurology, P.A.”, “we“, “us“, or “our” refer to On Demand Neurology, P.A and our affiliated Covered Entities (On Demand Neurology of CA, P.C., and On Demand Neurology of NJ, P.C.). and the terms “you” and “yours” refer to the person using the Service.

Our services are not intended for the provision of clinical diagnosis requiring an in-person evaluation and you should not use it if you need immediate/urgent care. We do not provide emergency medical consultation or prescribe any controlled substances.

‍

If you are thinking about suicide or if you are considering harming yourself or others or if you feel that any other person may be in any danger or if you have any medical emergency, you must immediately call the emergency service number (911 in the U.S.) and notify the relevant authorities. Seek immediate in-person assistance. WHEN IN DOUBT, PLEASE CALL 911 OR CONTACT YOUR LOCAL IN-PERSON HEALTHCARE PROFESSIONALS IMMEDIATELY.

Do not disregard, avoid, or delay in obtaining in-person care from your doctor or other qualified professional because of information or advice you received through our services.

‍

Possible Risks of Telemedicine.  Telemedicine involves the use of audio, visual, or other electronic communications to enable medical practitioners at different locations to share individual patient medical information for the purpose of providing patient care.

‍

• Information transmitted to your provider(s) may not be sufficient to allow for appropriate medical decision making by the provider(s).
• The inability of your provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you.
• Your provider may not be able to provide medical treatment for your particular condition via telemedicine and you may be required to seek alternative care.
• Delays in medical evaluation/treatment could occur due to failures of the technology.
• Security protocols or safeguards could fail causing a breach of privacy.
• Given regulatory requirements in certain jurisdictions, your provider(s) treatment options, especially pertaining to certain prescriptions may be limited.

‍

By accepting this Consent to Telehealth, you acknowledge your understanding and agreement to the following:

‍

• You are the person who is seeking a telemedicine evaluation, and that you are accepting this Consent to Telehealth on your own behalf.
• That you are at least 18 years old.
• You agree to participate in a telemedicine evaluation.
• You authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. [Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small].
• You understand that you can withdraw your permission at any time and that you do not have to answer any questions that you consider to be inappropriate or are unwilling to have heard by other persons.
• You understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for you to see a specialist in person.
• You understand that medical records of telemedicine services will be kept with Neura Health.
• You understand that some or all of your medical information may be used for teaching or educational purposes.
• You agree to have your telemedicine medical records reviewed for the purposes of evaluation (data collection, analysis and presentation in verbal or written format at scientific meetings).
• You understand that any presentation will not identify me by name or other identifiable markers.

‍

As it relates to your privacy, you understand that we are committed to gathering, accepting, using and disclosing your personal information and your personal health information professionally, responsibly, and only to the extent required in providing health related services. You agree that you have access to our full Privacy Policy and Notice of Privacy Practices and that you may obtain a written copy of either of those documents from us if you wish. You agree that we may record my telerehab session and use the recording for lawful purposes such as training, product improvement and to evaluate the quality of services that you have received. 

You agree that we may use your email address and other contact information as a means of providing you with information regarding my healthcare, including appointment bookings and account notifications.

‍

You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. However, you understand that we are a telemedicine-only provider, and that we may not be in a position to offer you future services if you withdraw your consent.

‍

‍

Contact Information:

support@neurahealth.co

+1-313-887-0960