Last Updated: May 17, 2019
I understand that Northwestern Hair, Inc.’s affiliated healthcare providers (“healthcare provider”) treat patients via telehealth, and I wish to be treated via telehealth. I understand that my telehealth treatment may involve all of the following (collectively “telehealth visit”):
Electronic creation and transmission of medical records, photo images, personal health information, or other data between me as the patient and healthcare providers and among healthcare providers and entities; Interactions between me and a healthcare provider via audio, video, and/or data communications (including store and forward technology); and Use of output data from medical devices, sound and video files; and
I understand there are potential risks to a telehealth visit, including interruptions, unauthorized access which could disclose my health information, and technical difficulties. I understand that my healthcare provider or I can discontinue the treatment via telehealth visit if it is felt that the situation warrants.
I understand that my care at Northwestern Hair is limited to the diagnosis and treatment of acne and skin aging and related disorders and not for the diagnosis or treatment of any other medical or dermatological conditions, including skin cancer. I understand that the Website is not a substitute for the in-person treatment or advice of my local dermatologist, primary care physician, or any other qualified healthcare professional. I understand that I should never delay seeking advice from my local dermatologist, primary care physician, or any other health professionals if advised to do so by my Northwestern Hair healthcare provider, or if I have any concerns.
I understand that Northwestern Hair undertakes no obligation to review the inactive ingredients and or the base ingredients in any product that is recommended or sold to me, including, without limitation, to ascertain that I am not allergic to such inactive or base ingredients. I further understand that it is solely my responsibility to review those ingredients, as listed on the Northwestern Hair website.
I understand that if I have an emergency health issue of any nature, I should call my local emergency medical number or take such other action as I deem necessary.
I understand that I have the right to request that the Medical Record established with Northwestern Hair be sent to my primary healthcare provider. I may request this on my dashboard.
Possible Benefits of Telemedicine
- Can be easier and more efficient for you to access medical care and treatment.
- You can obtain medical care and treatment at times that are convenient for you.
- You can interact with providers without the necessity of an in-office appointment.
Possible Risks of Telemedicine
- Information transmitted to your provider(s) may not be sufficient to allow for appropriate medical decision making by the provider(s).
- The inability of your provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you.
- Your provider may not able to provide medical treatment for your particular condition via telemedicine and you may be required to seek alternative care.
- Delays in medical evaluation/treatment could occur due to failures of the technology.
- Security protocols or safeguards could fail causing a breach of privacy.
- Given regulatory requirements in certain jurisdictions, your provider(s) treatment options, especially pertaining to certain prescriptions may be limited.
By continuing, I accept this Consent to Telehealth Treatment and I represent:
I have read or had this form read and/or had this form explained to me. That I fully understand its contents, including the risks and benefits of the telehealth service provided through Northwestern Hair platform by “Providers.”
I give my informed consent to the use of telemedicine by providers affiliated with Northwestern Hair.
I understand that the delivery of healthcare services via telemedicine is an evolving field and that the use of telemedicine in my medical care and treatment may include uses of technology not specifically described in this consent.
I understand that while the use of telemedicine may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed.
My condition may not be cured or improved, and in some cases, may get worse.
I understand that “Providers” may determine in his or her sole discretion that my condition is not suitable for treatment using telemedicine, and that I may need to seek medical care and treatment in-person or from an alternative source.
I understand that the same confidentiality and privacy protections that apply to my other health care services also apply to these telemedicine services.
I understand that I have access to all of my health and wellness information pertaining to the telemedicine services in accordance with applicable laws and regulations.
I understand that I can withhold or withdraw this consent at any time by emailing Northwestern Hair with such instruction. Otherwise, this consent will be considered renewed upon each new telemedicine consultation with “Providers”.
I agree and authorize my health care provider to share information regarding the telemedicine exam with other individuals for treatment, payment and health care operations purposes.
I agree and authorize my health care provider to release information regarding the telemedicine exam to Northwestern Hair and its affiliates.