Terms and Conditions
*By signing this form, I understand and agree with the following:
Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different
locations to share individual patient medical information for the purpose of improving patient care. Providers may
include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical
assistants and other healthcare providers who are part of my clinical care team. In addition to myself and the
members of my clinical care team, my family members, caregivers, or other legal representatives or guardians may
join and participate on the telehealth/telemedicine service, and I agree to share my personal information with such
family members, caregivers, legal representatives or guardians. The information may be used for diagnosis, therapy,
follow-up and/or education.
Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information,
which may include:
• Progress reports, assessments, or other intervention-related documents
• Bio-physiological data transmitted electronically
• Videos, pictures, text messages, audio and any digital form of data
The laws that protect the privacy and confidentiality of health and care information also apply to
telehealth/telemedicine. Information obtained during telehealth/telemedicine that identifies me will not be
given to anyone without my consent except for the purposes of treatment, education, billing and healthcare
operations. By agreeing to use the telehealth/telemedicine services, I am consenting to MyCouchDoctor.com sharing of my
protected health information with certain third parties as more fully described in MyCouchDoctor.com Privacy Policy. I
understand, agree, and expressly consent to [NAME] obtaining, using, storing, and disseminating to necessary
third parties, information about me, including my image, as necessary to provide the telehealth/telemedicine
services.
As with any Internet-based communication, I understand that there is a risk of security breach. Electronic
systems used will 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.
Individuals other than my clinical care team or consulting providers may also be present and have access to
my information for the telehealth/telemedicine session. This is so they can operate or repair the video or audio
equipment used. These persons will adhere to applicable privacy and security policies.
Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the
Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality,
dropped connections, audio interference) that prevent effective interaction between consulting clinician(s),
participant, patient or care team.
Refund is guaranteed on Fiat Payments, for Crypto security standards, if any problem showed up, you will rewarded two Consultation managed and scheduled by our admin team.
I hereby release and hold harmless MyCouchDoctor.com and all members of my care team from any loss of data or
information due to technical failures associated with the telehealth/telemedicine service.
I understand and agree that the health information I provide at the time of my telehealth/telemedicine service
may be the only source of health information used by the medical professionals during the course of my
evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not
have access to my full medical record or information held at MyCouchDoctor.com.
Telehealth Consent v.08.30.2021 2
I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable,
including the benefits, risks, possible problems or complications, and alternate choices for my medical care
through the telehealth/telemedicine visit.
We Offer Family Health and General Practice type of consultations, We assure changing your mindset and daily routines to achieve optimum results, No prescription should be accepted from our doctors except in case of OTC medications or in case our doctor is Licensed to practice medicine as at least a specialist at your country of residence at the time of your consultation. In case of Appoinments, You agree to accept our Speacialist’s advice and prescription in only Generic drug names. you hold yourself accountable for accepting any trade names without consulting your Family physician.
I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time and
revert back to traditional in-person clinic services. I understand that if I withdraw my consent for
telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled.
All my questions have been answered to my satisfaction.
I hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and
conditions.
By signing below, I certify that I am the legal representative of the participant or that I am the patient and am
18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the
above statements. I have had all my questions answered. I understand that this informed consent will become a
part of my medical record.
Signature of Patient or Patient’s Legal Representative
