Consent To Telemed

CONSENT FOR TELEHEALTH CONSULTATION

This Consent for Telehealth Consultation (this “Consent”) contains important information about providing certain services, including healthcare services, using the phone and/or the Internet. Please read this Consent carefully.

Telehealth: Telehealth services refer to consultations, including healthcare consultations, which are conducted remotely using interactive video conferencing and/or telephone communication technologies.

Benefits: Some of the benefits of telehealth services include the ability to have consultations without being in the same physical location, increased convenience, and typically shorter consultation times.

Risks: Some of the risks associated with telehealth services include the potential for other people to overhear consultations if you are not in a private place during the consultations. On our end, Revolution Rx and its service providers will take reasonable steps to ensure your privacy. It is important that you find a private place for our consultation. You are obliged to notify Revolution Rx of any other persons in the location, either on or off-camera, who can hear or see the session. It is also important for you to protect the privacy of our session on your cell phone or another device. You understand that it is your obligation to ensure that any virtual assistant artificial intelligence devices, including but not limited to Alexa or Echo, are disabled or not in the location where information can be heard. Additionally, it is possible that the technology being utilized may stop working during a consultation, other people might be able to gain access to our private consultation, or stored data could be accessed by unauthorized people or companies. You understand that Revolution Rx is not responsible for any technological problems over which Revolution Rx has no control. You further understand that Revolution Rx does not guarantee that technology will be available or work as expected.

Location: You understand that it is your obligation to notify Revolution Rx of your location at the beginning of each treatment session. If, for some reason, you change locations during the session, it is your obligation to notify Revolution Rx of the change in location.

Medical Health Information and Records: All existing laws regarding access to and protection of your medical and protected health information apply to telehealth services. However, please keep in mind that not all telehealth communications are recorded and/or stored.

Rights: You may withdraw your consent to telehealth services at any time.

Disputes: You agree that any dispute arising out of telehealth services will be resolved under the laws of the State of Colorado and shall take place within Arapahoe County, in the State of Colorado.

Consent: By signing this Consent, you acknowledge and agree that you have been advised of the risks and benefits of telehealth services, that you have had ample opportunity to ask questions about the information presented in this Consent, the nature of the consent requested herein, and about telehealth services, and you are executing this Consent fully informed and of your own free will.