I have read and understood this telehealth consent document and I consent to receiving Itsverdure services via telehealth technologies. I understand that Itsverdure and its providers are a telehealth only medical service provider whose interactions with me are electronic and that their services to me do not replace the relationship between mine or my children’s with their primary care provider. I also understand it is up to Itsverdure provider’s to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
 

I have been given an opportunity to select from a list of Itsverdure on call providers prior to the consult, including a review of the Provider’s credentials and that the choice of provider is mine
 

I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except for the purposes of treatment, education, billing and healthcare operations. I understand that “Itsverdure” will take steps to ensure that my identifiable personal health information will not be seen by anyone who has no business seeing it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
 

I understand there is a risk of technical failures during the telehealth encounter beyond the control of Itsverdure. I agree to hold harmless “Itsverdure” for delays in evaluation or for information lost due to such technical failures.
 

I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
 

I understand that if I am experiencing a medical emergency, “Itsverdure” providers may not be able to assist virtually and that I will be directed to dial 9-1-1 immediately. I also understand that “Itsverdure” Providers are not able to connect me directly to any local emergency services.
 

I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation with Itsverdure, I understand that some parts of the services involving tests may be conducted by individuals at my location when possible, or at a testing facility close to me,  at the direction of the Provider (e.g. labs or bloodwork).
 

I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
 

I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Also, persons may be present during the consultation other than the Provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request any or all of the following:   - omit specific details of my medical history/examination that are personally sensitive to me;  - ask non-medical personnel to leave the telehealth examination;  - and/or terminate the consultation at any time.
 

I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.
 

I understand that if I participate in a consultation, I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
 

I understand that I may be directed to use devices such as a thermometer, pulse oximeter, at-home tests, or other peripheral devices to assist in the provision of telehealth.
 

I will have a conversation with an Itsverdure provider, during which I will have the opportunity to ask questions in regard to the consultation and virtual encounter. I will have my questions along with the risks or benefits of any practical alternatives answered in a language that I understand and if not so, I will write within 24 hours of the consultation.
 

I understand and agree that the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by Itsverdure providers during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record or information held.
 

I agree that all my questions about this virtual encounter has been answered to my satisfaction prior to my appointment