I understand that telehealth is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual when he/she is located at a different site than the provider, but within the same state.
I understand that telehealth visits are reserved for mild to moderate symptoms and are not appropriate for severe or life-threatening illnesses.
I understand that medical evaluation, diagnoses, and treatment offered by Essentialyze Healthcare PLLC are virtual and/or asynchronous in the absence of a face-to-face physical examination. Therefore, it is important to follow up with your primary care provider for continuity of care.
I agree to follow up with a doctor of seek emergency care after a telehealth visit for further evaluation of your condition or sooner if symptoms do not improve or resolve in a timely manner.
I agree to call 911 or seek emergency care if symptoms or conditions worsen.
I agree to continue the recommended routine physical visit with an in-person physician while utilizing telehealth as secondary means of accessing healthcare.
I certify that I do not have any cognitive impairment and can make sound medical decisions.
I understand that I am consenting to a telehealth service, and I accept the risk of misdiagnoses due to the absence of in-person evaluation and/or diagnostic tools.
I understand that services rendered by Essentialyze Healthcare PLLC are provided on a non-refundable basis.
I understand that my payment to Essentialyze Healthcare PLLC does not cover prescriptive medications I still have to pay for the prescribed medication at the pharmacy and any other services outside of your telehealth visit. I understand that the information given on the medical intake forms must be complete, accurate and up to date to the best of my knowledge.
I understand that Essentialyze Healthcare PLLC reserves the right to decline treatment and reserves the right to practice under the discretion of the provider.
I hereby acknowledge that providing my personal information to Essentialyze Healthcare PLLC is voluntary and is required as a personal identifier to deliver telehealth services.
I understand that I am establishing a Provider-Patient relationship via telehealth and that I have read or had this form read and/or had this form explained to me, and I fully agree with its contents and risks and/or benefits of telehealth. I have been given ample opportunity to ask questions via Support@Essentialyze.com and any questions and/or concerns have been answered to your satisfaction before proceeding.
