eClinicMD Consent to Treatment and Release Agreement
I agree to consent to treatment and hold harmless of any claims against eClinicMD by agreeing to the following items:
I initiated the contact with eClinicMD and understand that its physicians may be located in a different state than the one in which I reside, and that the physician may not be licensed to practice medicine in my state of residence. I agree that all online, telephonic and/or video medical consultations, diagnoses, and treatments will be deemed to have occurred in the state where the physician is physically located and licensed to practice medicine.
eClinicMD reserves the right to refuse treatment to any person they deem necessary.
I acknowledge that eClinicMD has the authorization to charge my credit card for the consultion fee, and that consultation fees are only refundable at the discretion of eClinicMD.
I understand I am responsible for any customs, tariffs, or taxes, if applicable.
Patient's Responsibilities, Acknowledgements and Certifications:
I certify that my medical records are current, factual and have been obtained from my current physician and my identification that I am providing is factual and not altered in any manner.
I understand that it is my responsibility to comply with all protocols-including the annual physical examination (with any suggested laboratory tests)-to ensure that I have no disease(s) that might make any therapies (including prescription drugs) inappropriate for my condition. I also understand that it is my responsibility to provide a complete and accurate medical history. I hereby authorize eClinicMD to obtain any additional medical records or to consult with any of my current or former treating or examining physicians to ensure a complete evaluation of my medical condition.
I understand that if treatment is prescribed, it is possible that I may suffer potential adverse effects and that no physician, nurse, pharmacist or medical staff personnel can guarantee clinical benefit from prescribed treatments.
I further acknowledge that if I suffer adverse conditions, side effects or any other problems with my treatment or medication(s) I must notify eClinicMD immediately. I also agree not to hold eClinicMD personnel, physicians, pharmacies or anyone associated with eClinicMD liable for such condition(s) in any manner.
I certify that I am 21 years of age or older and that I have answered all questions honestly and am able to make my own decisions based on my medical condition(s).
I agree to hold harmless eClinicMD, its staff, employees, physicians, pharmacies, or anyone associated with eClinicMD in respect to liability of treatment, consultations and medications.
I certify that my medical condition(s) is a real, legitimate medical condition(s) and that I have a need for treatment.
I agree to notify any other physicians that I am working through eClinicMD physicians for my medical condition(s).
I acknowledge that it is my responsibility to have an annual physical examination to further ensure my treatment is correct for my condition(s).
I agree to furnish all updated medical records to eClinicMD as it is deemed necessary.
Summary of Consent and Release
I have read and understand this "Consent to Treatment and Release Agreement" and accept its terms with an understanding of the medical and legal risks. I understand that I should consult my attorney or another healthcare provider, as appropriate, should I have any questions about this agreement.
I understand that submitting false information or making false statements in order to obtain prescription medication or other medical care is a violation of federal and state statutes and law, so I have and will continue to answer all questions truthfully.
I understand and agree that I am accepting the terms of this "Consent to Treatment and Release Agreement" by selecting the statement "I have read and agree with the Consent to Treatment and Release Agreement" on the eClinicMD online consult request form. I acknowledge this constitutes the equivalent of my signature on a binding agreement between eClinicMD and I.