To improve patient experience, we have centralized all subscriptions under our digital health brand Medzino. You will now be redirected to our brand Medzino to complete the appointment request. We are still the same team behind the service but only changing the intake process.
Informed Consent for Medical Services
Informed Consent for Medical Services I understand that various procedures may occasionally be recommended by my provider. These procedures may be relatively routine such as an injection of a medication or a more detailed procedure such as thyroid ultrasound, fine needle aspiration, etc. I understand that all procedures have some degree of risk associated with them, including the possibility of allergic reaction, vascular, nerve, tendon, or tissue damage, infection, scarring, rash, bleeding and under rare and unusual circumstances, disability or death. I understand the possibility of routine complications and side effects of any medication prescribed or administered either by injection or by mouth, given in the clinic or prescribed to be taken at home. I understand that there is no medicine that is entirely free of potential side effects which are usually mild but could potentially be severe, I accept the possibility of complications or even the chance of severe allergic reaction resulting in death. I accept the responsibility to discuss any concerns with my provider and the pharmacist. I will not take or accept any medication or procedure unless all of my concerns& questions have been addressed to my satisfaction. I will remind and make sure that my provider is aware of any allergies that I have, or past unacceptable side effects to medications or procedures and even the possibility of pregnancy.
Educational Consent This organizationis an educational organzation participating in the training of student nursesand other health care personnel. I agree that they may participate in my careto the extend deemed appropriate by TeleMed2U Staff.
Consent Form for Treatment of Minors With Divorced or Separated Parents
TeleMed2U will not initiate treatment for minors of divorced parents until we have been provided with a copy of a legal divorce decree or custody agreement. Any parents or legal guardians who are listed in the decree as having a medical and/or psychiatric decision-making authority must sign this treatment consent form prior to initiating a treatment plan. It is not the responsibility of TeleMed2U or any of its affiliates to ensure that parents and legal guardians adhere to the terms of a legally binding divorce decree.
We expect divorced parents to communicate with each other about services rendered and to determine who will schedule appointments, who will bring the child to treatment, who will administer medication, etc. The clinician and the child will not be the messenger between parents.
Consent for the minor patient's treatment must be given by both parties during the scheduled appointment, either by both parties being present at the appointment, or by one party being present by telephone during the appointment. Your clinician cannot take time from your child's care by contacting you to obtain consent before or after the appointment. Violation of this policy will result in termination of care.
Failure of one or more of a minor patient's medical decision-makers to agree to the recommended treatment plan will result in the minor patient's care being discontinued.
Your initials indicate that you will not request or require your clinician or others affiliated with TeleMed2U, through subpoena, summons, or other means, to provide testimony in any legal proceeding relating to the care and custody of your child. We will not testify in court about custody issues as it is not our role to conduct custody evaluations, determine whether a parent is "fit" to fulfill parental duties.
Statement of Legal Guardian
I give my permission to the other legal guardian and my child's clinician(s) at TeleMed2U to make decisions regarding pharmacologic and therapeutic interventions, scheduling appointments, and canceling appointments, if I am not physically present during any appointments.
I accept the responsibility of communicating with the other legal guardian after every appointment regarding any change in the treatment plan. I understand my child's clinician will not contact me outside of my child's scheduled appointment time to obtain consent for these changes; however, I may contact the clinician if I wish to withdraw consent to a change in treatment regimen.
I understand that failure of myself and my child's other legal guardian to agree to the recommended treatment plan will result in my child's care being discontinued with the provider. I understand that if the above policies are violated, or I choose not to adhere to these policies, my child's care will discontinued.
TeleMed2U Informed Consent For Participation in Therapy
I consent to participate in tele mental health services with a TeleMed2U provider as part of my psychotherapy. I understand that tele mental health is the practice of delivering clinical health care services via technology-assisted media or other electronic means between a practitioner and a client who are located in two different locations.
I understand the nature of counseling: The type and extent of services that I will receive will be determined following an initial assessment and through discussion with me. I understand that there maybe both benefits and risks associate with participation in counseling. Counseling may improve the ability to relate to others, provide a clearer understanding of self, values, and goals. I understand that counseling may also lead to unanticipated feelings of change, which might have unexpected impact on me and my relationships.
I understand the following with respect to tele mental health:
1. I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
2. I understand that there are risks, benefits, and consequences associated with tele mental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
3. I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
4. I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to tele mental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
5. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that tele mental health services are not appropriate and a higher level of care is required.
6. I understand that if I am under the age of 18 that the privacy laws that protect confidentiality still apply and the provider is mandated to break confidentiality in situations detailed above.
7. I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
Why do I need to sign this if I am not getting therapy from you? Although we might not be delivering therapy to you right now, having the consent on file is required should you and your provider agree to include therapy as part of your personalized treatment plan in the future and the therapy is delivered by one of our therapists.
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