1. I consent to and understand that my health care provider wishes me to engage in a tele-health consultation.According to California Business and Professions Code § 2290.5(a)(6) Telehealth means “the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and a synchronous store and forward transfers”. Synchronous interaction which means a real-time interaction between a patient and a health care provider located at a distant site.
2. I understand that the patient-provider interaction is not in person (directly). The health care provider has explained to me how the video conferencing technology will be used to affect such a consultation. I fully acknowledge that this consultation will not be the same as a direct patient/health care provider visit due to the fact that the patient and provider will not be in the same room as my health care provider.
3. I fully acknowledge there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that Dr2bthin’s medical staff or myself can discontinue the tele-medicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.(Once you fill in the patient form on our website with all your medical history you will be contacted by one of our trained medical staff with instructions for TELE CONFERENCE.You will have a face to face consultation &if we feel Phentermine is right for you from your patient form you may not get a call.
4. I understand that my information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than Dr2bthin’s medical staff in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. 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/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the tele-medicine examination room; and/or (3) terminate or reschedule the consultation at any time.You have provided us honest medical information on your health form and you must continue to answer to all questions diligently on Tele Health platform.You must also have available your ID TO SHOW ON THE SCREEN.
5. I understand that my information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than Dr2bthin’s medical staff in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. 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/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the tele-medicine examination room; and/or (3) terminate or reschedule the consultation at any time.You have provided us honest medical information on your health form and you must continue to answer to all questions diligently on Tele Health platform.You must also have available your ID TO SHOW ON THE SCREEN.
6. Despite reasonable security measures, online communications can be forwarded, intercepted, or even changed or falsified without my knowledge. In addition, the information transmitted to my healthcare provider may be insufficient to provide a proper diagnosis or treatment, or to identify the need for emergency medical care. My “Healthcare provider relies on my accurate and truthful representation in making diagnostic and treatment determinations.”
7. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider if needed.In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference connection.In any emergency my physician may contact 911.
8. I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby consent to participate in a telemedicine visit under the terms described herein.

I have fully read and understood the above information.