Qualiphy Patient Telehealth Assessment Consent and Release of Liability

PLEASE READ AND MAKE SURE YOU FULLY UNDERSTAND THE FOLLOWING TERMS PRIOR TO YOUR TELEHEALTH ASSESSMENT: This telehealth medical screening evaluation is not a general or complete medical examination. This telehealth screening examination is solely for purposes of assessment, and only focuses on establishing whether or not it is medically appropriate for you to receive certain specific medical aesthetics treatments. Today’s telehealth clinical evaluation with a licensed provider of Qualiphy PC (“Qualiphy”) is not intended to diagnose or treat any medical disorder or condition and is only for purposes of assessing your health as it relates to whether you may receive certain specified medical aesthetics treatments. The relationship established with the Qualiphy 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 will be no 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.