Informed Consent

Telehealth Informed Consent

By affirmatively using this site’s services, I acknowledge that I have reviewed and agree to the below terms as they relate to receiving medical care from Metaderm, PLLC d/b/a Skinclusive Dermatology (“Skinclusive”) and its individual licensed physicians, nurse practitioners, and/or physician assistants (each of whom may be a “Treating Provider”). I further understand that such care will be provided via telehealth. 

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. Telehealth services offered by Skinclusive may typically include, without limitation, asynchronous communications, interactive audio-visual consultations, medication management, laboratory services, remote prescribing, health information sharing (including care coordination with your other treating providers), and non-clinical services, such as patient education.  

The electronic communication systems we use incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Your Skinclusive Treating Providers are intended to be an addition to, and not a replacement for, your primary care provider.  Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.

Telehealth has a number of expected benefits, but also some possible risks. 

Expected benefits of telehealth include:

• Improved access to care by enabling you to remain in your home while your provider consults and obtains test results at distant/other sites.
• More efficient care evaluation and management.
• Obtaining expertise of a specialist as appropriate.

Possible risks associated with telehealth can include: 

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
• In rare events, the Treating Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with a local provider.
• In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

Disclosures Specific to California Patients:

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

NOTICE TO PATIENTS

Medical doctors are licensed and regulated by the Medical Board of California.

To check up on a license or to file a complaint go to

www.mbc.ca.gov,

email: licensecheck@mbc.ca.gov,

or call (800) 633-2322.

* * * * *

 I acknowledge and agree that:

• I consent to receive diagnostic, therapeutic, or other medical dermatology care (collectively the “Services”) from Skinclusive and Treating Providers through the use of a telemedicine platform. 
• Any medications shall be prescribed by the Treating Provider only when it is determined to be necessary and/or appropriate in the professional medical judgment of my Treating Provider. I understand that any treatment of my condition(s) will be dependent on a review of my medical history, medical records, and current medical status (collectively “Medical Information”) by my Treating Provider. 
• I agree to provide accurate, complete, and up-to-date Medical Information to Skinclusive and my Treating Provider, and that such information will be relied upon in the provision of Services to me. Incomplete or inaccurate information may impact the efficacy of the Services.
• I will be provided with information related to my diagnosis, treatment, and ongoing care, and that the success of my treatment and care is dependent upon my review of this information. Therefore, I agree to review all such information Skinclusive provides to me.
• I may decline treatment at any time. 
• There is a risk of technical failures during the telehealth encounter beyond the control of Skinclusive. I agree to hold harmless Skinclusive for delays in evaluation or for information lost due to such technical failures.
• I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
• I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.
• I understand there may be side effects from certain medications prescribed, and that my Treating Provider will specifically address these risks when prescribing such medication to me.
• I understand Skinclusive is not equipped to handle medical emergencies. If I have an emergency that needs immediate response, I will call 911 or go to my nearest emergency room.
• I will provide advance notice to Skinclusive if I will be located outside of my state of residence during a scheduled appointment.