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By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:

  • I hereby consent to receiving Live Life Now Health’s services via telehealth technologies and understand that I am establishing a clinical relationship with Live Life Now Health. I understand that Live Life Now Health and its providers offer telehealth-based healthcare services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Live Life Now Health provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
  • I have been given an opportunity to select a provider from Live Life Now Health prior to the consult, including a review of the provider’s credentials.
  • I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Live Life Now Health will take steps to make sure that my health information is not seen by anyone who should not see 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 Live Life Now Health. I agree to hold harmless Live Life Now Health 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, that I will be directed to dial 9-1-1 immediately and that the Live Life Now Health 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, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Live Life Now Health 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. Persons may be present during the consultation other than the Live Life Now Health 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 the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) 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, that 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.

Patient Consent

I have read this document carefully and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.

□ ACCEPT. By checking the Box for this “INFORMED CONSENT FOR TELEHEALTH SERVICES” I hereby state that I have read, understood, and agree to the terms of this document.