VIRTUAL CONSULT CONSENT
A Virtual Consult (also called telemedicine or telehealth) refers to the use of technology (i.e. video, audio or/or text chat) by a physician or nurse practitioner (“health care practitioner”) to provide health care services from a distance. Although a Virtual Consult provides convenience and access to health care services, I understand that in many situations the health care practitioner can make a more accurate assessment in person with a physical examination.
I understand that before proceeding with a Virtual Consult, the health care practitioner will consider my health care status, my specific health needs and will assess the potential risks and benefits in order to determine whether a Virtual Consult is appropriate in the circumstances. I understand and agree that the health care practitioner has sole discretion to determine whether to proceed with a Virtual Consult.
I understand and agree that:
- the health care practitioner is conducting a Virtual Consult, but is not assuming my care and will not serve as my primary care physician or health care provider. I agree to seek regular medical care from my primary care physician or health care provider and specialist(s) as required.
- the health care practitioner is relying on the accuracy and completeness of the personal health information that I provide and has no role or responsibility for determining the accuracy of the information provided by me.
- I will identify myself with photo ID issued by a government institution and will confirm my location. I will inform the health care practitioner of any change to my email, cell phone number or any information required to use the service.
- the health care practitioners who provide Virtual Consults are licensed by their provincial health regulatory body. The health care practitioner conducting the Virtual Consult may not be physically located in the province in which I reside. I understand that depending on the licensing requirements of the province in which I am located, the health care practitioner may or may not need to be licensed in my province.
- if the health care practitioner providing the Virtual Consult recommends treatment or prescribes medication for me, they will be responsible for advising me of the potential risks, consequences and benefits of the treatment or medication and will obtain my informed consent.
- I will identify if I am seeking a Virtual Consult for myself or on behalf of someone else. I understand that minors who are capable of making their own treatment decisions may seek a Virtual Consult on a confidential basis, without their parent’s consent, provided that they have been registered through their parent’s account and this use has been authorized.
- Virtual Consults involve the communication of sensitive personal health information electronically and occur in real time. Information communicated through a Virtual Consult may include details of my medical history and condition(s), symptoms, examinations and diagnoses. The use of technology may increase the risk of my personal health information being unintentionally disclosed or intercepted by third parties.
- Although Virtual Consults are provided over a secure platform and reasonable efforts are made to protect the privacy and security of my personal health information, it is not possible to completely secure electronic information.
- It is my responsibility to ensure that the technology and setting at my end are secure. I will inform the health care practitioner if my location doesn’t provide adequate privacy to protect my personal health information.
- Technical failures and technological issues may result in a loss of personal health information and/or delay or interruption of my Virtual Consult.
- VirtualMED and the health care practitioner assume no responsibility or liability for technical failures or technological issues associated with my software, hardware, or internet service provider.
Consent to the Collection, Use and Disclosure of Personal Health Information
I understand that in order to assess my health care needs and to provide Virtual Consults, it is necessary for VirtualMED to collect, use and disclose personal health information about me. I understand that VirtualMED will create an electronic health record for me and that my personal health information will be transmitted and stored on HealthTap’s secure servers in the US. I understand that VirtualMED is responsible for my personal health information, including when it is being handled by a third party on its behalf.
I understand that I may withdraw my consent at any time, however, this does not have retroactive effect.
Consent to Virtual Consult
I have been advised and understand the nature, potential risks, consequences and benefits of a Virtual Consult. I have had the opportunity to ask questions and to receive responses.
I understand that it is my decision whether to participate in a Virtual Consult and that I can withhold or withdraw my consent at any time, without affecting my right to future VirtualMED services.
I agree to release, hold harmless and indemnify VirtualMED, HealthTap, the health care practitioner and their respective directors, officers, employees, independent contractors, or agents (the “Indemnified Parties”) from and against any losses, disputes, complaints, legal claims, damages, expenses, costs or liability (collectively, “Losses”) arising out of or related to any failure of technology or equipment or breach of privacy or security in connection with the provision of a Virtual Consult, attributable to my misuse or failure to comply with my obligations relating to a Virtual Consult, or arising from or in connection with the provision of Virtual Consults, whether or not any such Losses arise from or relate to negligence on the part of the Indemnified Parties.