Telehealth Consent, Consent To Treat & Release Of Liability

PLEASE READ AND MAKE SURE YOU FULLY UNDERSTAND THE FOLLOWING

Patient Information and Agreement
By clicking accept to continue with the telemedicine consultation, I agree to the terms set forth herein this Telehealth Consent, Consent to Treat and Release of Liability.  Whether synchronous or asynchronous, this Telehealth Consent and Consent to Treat Form (the “Consent Form”), I, , acknowledge that I am consenting to engage in telehealth services and receive treatment as described below. I understand that these services are provided by Qualiphy and facilitated by my referring clinic, which remains my primary point of contact for all questions and ongoing care.

1. Telehealth Consent

I understand and agree that:

• Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. This may include video consultations, electronic transmission of patient records, and other forms of communication.
• The telehealth services provided by Qualiphy may include, but are not limited to, consultations, follow-up appointments, and treatment guidance.
• The benefits of telehealth include easier access to medical care and convenience for the patient. However, I am aware that there are potential risks, such as technology failures and data breaches, despite all reasonable security measures being taken.
• I have the right to refuse telehealth services at any time without affecting my right to future care or treatment.

2. Consent to Treatment

I consent to receive treatment, which may include but is not limited to:

• General Telehealth Consultations
• Aesthetic Procedures, including but not limited to Neuromodulator (e.g., Botox, Dysport) treatments, Dermal Fillers, Laser Hair Removal, and IV Therapy.
• Prescription and Administration of Medications including GLP-1 Medications, including Semaglutide and Tirzepatide in various forms such as injectables, tablets, nasal sprays, and sublingual drops.

I understand that all procedures carry certain risks, including but not limited to pain, bruising, swelling, infection, allergic reactions, and in rare cases, more severe complications. I agree that I have had the opportunity to ask questions about the procedures and medications and have received satisfactory answers.

3. Informed Consent for Specific Treatments

A. Liability Acknowledgment: I agree that Qualiphy is not responsible or liable for any exams or treatment plans created, administered, or modified by clinics and their medical directors. This includes, but is not limited to, any advice, treatment outcomes, complications, or adverse reactions resulting from these custom exams.

B. Clinic Responsibility: The referring clinic and its medical director are solely responsible for ensuring that any exams comply with applicable laws, regulations, and medical standards of care.

C. Patient Responsibility: I understand that it is my responsibility to direct any questions or concerns about custom exams or treatment plans to the clinic that provided them, and I agree to hold Qualiphy harmless from any claims or disputes arising from such exams.

D. Neuromodulator and Filler Treatments

• Potential risks include temporary redness, swelling, allergic reactions, bruising, asymmetry, infection, and rare instances of nerve damage.
• I understand that results may vary and are not guaranteed.

E. Laser Hair Removal

• Potential risks include skin irritation, redness, pigmentation changes, and scarring.
• I understand that multiple treatments may be required for optimal results.

F. IV Therapy

• Risks may include bruising, vein inflammation, infection at the injection site, and rare cases of fluid overload or allergic reaction.
• I confirm I am aware of my current medical status and have disclosed any relevant medical history.

G. Semaglutide and Tirzepatide Treatments

• Potential risks and side effects of these medications include nausea, vomiting, diarrhea, potential allergic reactions, and, in rare cases, more severe side effects like pancreatitis or kidney issues.
• I understand that lifestyle changes and consistent medical follow-up may be necessary for effective treatment.

4. Indemnification Clause

By signing this Consent Form, I agree to indemnify and hold harmless Qualiphy, its affiliates, providers, and staff from any and all claims, liabilities, damages, or expenses that may arise from my participation in telehealth services and any subsequent treatment, whether related to the aforementioned aesthetic procedures, medication administration, or any other care provided.

5. Acknowledgment of Primary Point of Contact

I acknowledge that my referring clinic remains my primary point of contact for ongoing care, questions, and follow-up. I understand that:

• Qualiphy provides telehealth services in collaboration with my clinic, and any questions, follow-ups, or issues must be directed to and managed by the referring clinic.
• Should I require further assistance or have concerns following my treatment, it is my responsibility to contact the clinic that facilitated the telehealth service.

6. Privacy and Confidentiality

I understand that all information shared during my telehealth consultation is confidential and protected by applicable privacy laws. I have been informed that any data transmitted may be subject to security risks, despite Qualiphy’s efforts to maintain the highest standard of digital security.

7. Voluntary Consent

I confirm that I have read and understood this Consent Form, that I am of sound mind and body to make this decision, and that I agree to the terms stated above voluntarily. I also understand that I may request a copy of this form for my records.

The relationship established with the provider conducting your telehealth examination is not a replacement or substitute for in-person screening or ongoing medical care from your healthcare providers. Additionally, the medical evaluation conducted today with Qualiphy does not guarantee that you will be approved for any specific medical aesthetics treatment, and it does not guarantee any
successful outcome of any medical aesthetics treatment that may be approved. Some medical disorders may require additional medical evaluation, diagnostic testing, and/or medical records as deemed appropriate by the licensed healthcare professionals at
Qualiphy to determine if it is appropriate for you to receive a specified medical aesthetics treatment. Additionally, Qualiphy is solely providing screening to determine if it is appropriate for you to receive a treatment. Qualiphy providers are not providing any medical aesthetics treatments and are not responsible for the outcome of any medical aesthetics treatments provided to you by the medical aesthetics clinic who has connected you to our screening service.

Qualiphy is a telehealth platform that complies with HIPAA and wants to exchange text messages with you. 

Text messaging may not be entirely secure. To consent, click Accept.  
As with any medical treatment, there is a potential for adverse effects, and you should
ensure that you are fully informed about the potential risks, benefits, and alternatives to
any medical aesthetics treatment you are seeking. You should ask the provider
performing the treatment to fully discuss the risks, benefits, and alternatives with you so
that you may give your informed consent to proceed with treatment. If Qualiphy and its
healthcare providers determine following this telehealth assessment that it would
be medically appropriate for you to receive any specified medical aesthetics
treatment, it is expressly understood that Qualiphy and the Qualiphy providers
are not responsible for the outcome of any such medical aesthetics treatments.
Qualiphy does not approve, review, or endorse any of the medical aesthetics
clinics or providers who use our screening service for our patients.
By using our service, you acknowledge that you understand and agree to
the following:
I understand that HIPAA compliant and secure video conferencing technology will
be used to perform the screening consultation. I understand that this consultation

will not be the same as a direct patient/healthcare provider in-person since I will
not be in the same room as the Qualiphy healthcare provider.
I understand there are potential risks to telehealth including: There is the
potential that conditions that could be evaluated with an in-person visit may go
undetected in a remote encounter especially because a full physical exam cannot
be performed; there may be technical difficulties; the video picture or information
transmitted may not be clear enough to be useful for the consultation or to allow
for appropriate assessment; and rarely, there may be unauthorized access to the
video connection during the consultation despite using a secure connection.
I understand that the federal and state laws that protect the privacy and
confidentiality of health information also apply to telemedicine and all medical
reports resulting from the telemedicine consultation are part of my medical record
and will be shared with the medical aesthetics clinic providing medical aesthetics
treatments to me.
I understand that there may be a recording of any of the online session and that
all information disclosed within telemedicine sessions and in the written records
pertaining to those sessions are subject to the same HIPAA privacy protections
as in-person visits. They will only be shared with the medical providers and
clinics providing medical aesthetics treatments to me.
I understand that I am responsible for security on my device, including but not
limited to, computer, tablet, or phone. I also understand that I am responsible for
using this technology in a private location so that others cannot hear my
conversation. I will select a location for my sessions that is quiet, private and
sufficiently well-lit to allow the provider to easily see my face during the visit
Limited Involvement. I understand that the Qualiphy provider conducting my
telemedicine evaluation only has the information about me provided by the
medical aesthetics clinic where I am seeking treatment and the information that I
provide to the Qualiphy provider. I understand that the Qualiphy providers are not
providing ongoing care and are solely assessing my health as it relates to
whether it’s appropriate for me to receive specific medical aesthetics treatments.
I understand that the Qualiphy provider I see via telehealth for assessment will
have no further involvement in my care following my telemedicine evaluation and
responsibility for all medical aesthetics treatments and outcomes of treatments is
with the medical providers who are providing the treatments to me. I understand
that Qualiphy does not review the qualifications of any providers I may see for my
medical aesthetics treatments.
Complete Medical Information: I understand that certain medical aesthetics
treatments may be contraindicated if I have certain medical conditions, allergies
and/or take certain medications. I will truthfully and accurately disclose all
personal medical information including but not limited to: all of my health
conditions, my use of all medications, herbs, vitamins, and other supplements;

and all known allergies to drugs or other substances or any past reactions to
treatments requested by the Qualiphy provider assessing me. I understand that
failure to do so may negatively affect my treatment outcome and the safety of the
treatment I am seeking, and there shall be no liability on the part of Qualiphy or
the Qualiphy providers if I fail to do so. I understand that I must inform the
Qualiphy provider if I am pregnant or am breastfeeding
Release from Liability. I hereby agree, on behalf of myself, my heirs and my
personal representatives, to fully and forever discharge and release Qualiphy
and its affiliates, and their respective owners, operators, managers, employees,
contractors, and representatives, including licensed healthcare providers
(“Released Parties”) from any and all claims I may have or hereinafter have for
any injury, temporary or permanent disability, death, damages, liabilities,
expenses and/or causes of action, now known or hereinafter known in any
jurisdiction in the world, attributable or relating in any manner to the medical
aesthetics treatments that I receive after medical screening approval from
Qualiphy. I acknowledge and agree that Qualiphy and its providers are NOT
providing the medical aesthetics treatments to me and do not assess the
qualifications and skill of the providers who are providing the treatments, and the
Released Parties take no responsibility for the outcome of any treatment I
receive. I acknowledge and agree that this release is intended to be, and is, a
complete release, as much as allowed by law, of any responsibility of the
Released Parties for all personal injuries, temporary or permanent disability,
death, and/or damage sustained by me from receiving any medical aesthetics
treatments.
Covenant Not to Sue. I agree, for myself and all my heirs, not to sue the
Released Parties or initiate or assist in the prosecution of any claim for damages
or cause of action against the Released Parties which I or my heirs may have as
a result of any personal injury, death or property damage I may sustain due to
receiving any medical aesthetics treatments.
No Representations or Guarantees by Qualiphy. I acknowledge that while
Qualiphy providers may assess whether or not it is medically appropriate for me
to have specified medical aesthetics treatment, Qualiphy makes no
representation as to the qualifications of the providers who I have selected to
perform the treatment. Further, I understand that Qualiphy makes NO
representations or warranties about the outcome of any treatments I may
receive. I understand that there are risks to all medical aesthetics treatments and
I should ensure that I am fully informed about the risks and alternatives prior to
receiving treatment.
By continuing to use the Qualiphy Service, I acknowledge that I have read this document carefully and
understand risks and terms of the telehealth consultation provided by Qualiphy, and I
hereby consent to participate in a telemedicine consultation under the terms described
herein.