INFORMED CONSENT FOR TELEHEALTH SERVICES
YOU UNDERSTAND THAT BY CHECKING THE “AGREE” BOX YOU ARE AGREEING TO THIS INFORMED CONSENT AND THAT IT CONSTITUTES A LEGAL SIGNATURE ON THIS INFORMED CONSENT FOR TELEHEALTH SERVICES.
Portrait is pleased to offer telehealth services as a convenient option to consult with you and address your healthcare needs. Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment and follow-up. The telehealth services we offer may also include chart review, remote prescribing, health information sharing, and patient education.
During your telehealth consultation, details of your medical history and personal health information may be discussed through the use of interactive video, audio and telecommunications technology. A physical examination of you may also take place, and video, audio and/or photo recordings may be taken. The telehealth services we provide may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output date from medical devices and sound and video files.
The electronic communications systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data, and will include measures to safeguard the data and ensure its integrity against intentional and unintentional corruption.
Our physicians, physician assistants and nurse practitioners are in addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.
The purpose of this form is to obtain your consent for a telemedicine consultation with a Portrait healthcare provider.
Anticipated Benefits Of Telehealth Services
The use of telehealth services may have the following benefits:
While the use of telehealth services can provide potential benefits for you, there are also potential risks associated with the use of telehealth. These risks include, but may not be limited to, the following:
Patient Acceptance and Consent
By clicking the button titled “I Agree and Consent” on the electronic version of this form, you acknowledge that you have thoroughly read and understand this Informed Consent for Telehealth Services, and that you agree with each of the following:
Partner Pharmacy Contact Information
Prescriptions are filled by our partner pharmacy:
Welcare Pharmacy Compounding & Prescriptions
1921 W San Marcos Blvd #140
San Marcos, CA 92078
+1 (760) 727-3333