Telemedicine/Telehealth Consultation

Authorization and Consent to Participate in Telemedicine/Telehealth Consultation

The purpose of this form is to obtain your consent to participate in a telemedicine consultation with a Protocol Health Club provider.

1. Nature of Telemedicine Consultation: During the telemedicine consultation:

a) Details of you and/or your medical history, examinations, and laboratory tests will be discussed with other health professionals through the use of interactive video, audio and telecommunications technology.
b) Physical examination of you may take place.
c) Nonmedical technical personnel may be present in the telemedicine studio to aid in video transmission.
d) Video, audio, and/or digital photo may be recorded during the telemedicine consultation visit.

2. Medical Information and Records.
All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Additionally, dissemination of any patient-identifiable images or information from this telemedicine interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws.
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By agreeing to this document, you agree to allow Protocol Health Club to share your results and information with your coaching company, if your bloodwork was paid for by the coaching company.

3. Confidentiality
Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation. All existing confidentiality protections under federal and state law apply to information disclosed during this telemedicine consultation.

4. Risks and Benefits.
The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician.

My health care practitioner has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.

_{I understand that by submitting an application to book a sales call, I am providing written instructions authorizing PROTOCOL HEALTH CLUB, LLC and its affiliates to obtain my personal credit profile or other information from credit reporting agencies under the Fair Credit Reporting Act (FCRA) solely to conduct a credit pre-qualification. I further understand that this is a soft inquiry and will not impact my credit score in any way whatsoever.}