BY CHECKING THE “AGREE” BOX I AM CONSENTING TO THE PROVISION OF TELEHEALTH SERVICES AND CONFIRMING I HAVE READ THE “CONSENT TO TELEHEALTH SERVICES”.
Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or member education, and may include, but is not limited to:
The electronic systems used in the Science Service will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.
Possible Benefits of Telehealth
Possible Risks of Telehealth
By accepting this Consent to Telehealth, you acknowledge your understanding and agreement to the following:
I agree and authorize my health care provider to release information regarding the telehealth exam to Science and its affiliates.
If your physician has indicated that a controlled medication may assist in your symptomatic relief you agree to the following.
Controlled medicine can be dangerous and habit forming. These medicines must be taken only as prescribed by your doctor. Please read this consent and agreement thoroughly and ask any questions you may have. If you are in agreement and fully understand the benefits and risks of the medications, sign and date below.
• I understand that the medication I am being prescribed may cause addiction, but my physician feels it is necessary for treatment of my condition. My physician has explained to me the potential risks, the potential short and long term side effects; the risk of drug interactions and over-sedation; the risk of misuse and overdose. I accept these risks.
• I agree to take this medication only as prescribed by my physician.
• I agree to attend all scheduled appointments with my physician, PA or Medical Assistant.
• I understand that refills will not be given early.
• I will not obtain controlled substances from any other providers unless authorized by my primary prescriber, because it may be considered illegal to obtain controlled substances from multiple providers.
• I understand that these medications are for my personal use only.
• I understand that it is illegal, and can be reported to the police, to give or sell my medication to others.
• I agree to not use any illegal substances, including but not limited to marijuana, cocaine, or any other “street drugs”.
• I understand that it is illegal for me to use medications that are not prescribed to me.
• I understand that I am responsible for my own medication. Lost or stolen medication will not be replaced.
• I give up the right to privacy protections with regard to my prescription for controlled substances. The physician or his staff may talk with other physicians, pharmacists or family members to confirm appropriate medication use.
• I understand that I may obtain my controlled substances from only one pharmacy, and I agree to update my physician’s office of any changes in the pharmacy I use.
• I understand these medications may interfere with my ability to drive and/or operate heavy machinery.
• I have reviewed this Informed Consent and Treatment Agreement for Controlled Substances. I understand it and continue to agree to honor the Agreement. I understand that failure to do so may result in my discharge from this medical practice.
Last updated June 3, 2021
Thank you for choosing to be part of our community at Science (“Company”, “we”, “us”, or “our”). We are committed to protecting your personal information and your right to privacy. If you have any questions or concerns about our policy, or our practices with regards to your personal information, please contact us at email@example.com.
1. WHAT INFORMATION DO WE COLLECT?
Personal information you disclose to us
In Short: We collect personal information that you provide to us such as name, address, contact information, passwords and security data, and payment information.
We collect personal information that you voluntarily provide to us when registering at the Services or Apps, expressing an interest in obtaining information about us or our products and services, when participating in activities on the Services or Apps (such as posting messages in our online forums or entering competitions, contests or giveaways) or otherwise contacting us.
The personal information that we collect depends on the context of your interactions with us and the Services or Apps, the choices you make and the products and features you use. The personal information we collect can include the following:
Publicly Available Personal Information. We collect first name, maiden name, last name, nickname, ID, email addresses, phone numbers, and other similar data.
Personal Information Provided by You. We collect data about health, medical records, and similar apps, financial information (credit card number, purchase history, invoices), and other similar data.
Credentials. We collect passwords, password hints, and similar security information used for authentication and account access.
Payment Data. We collect data necessary to process your payment if you make purchases, such as your payment instrument number (such as a credit card number), and the security code associated with your payment instrument.
All personal information that you provide to us must be true, complete and accurate, and you must notify us of any changes to such personal information.
Information automatically collected
In Short: Some information – such as IP address and/or browser and device characteristics – is collected automatically when you visit our Services or Apps.
We automatically collect certain information when you visit, use or navigate the Services or Apps. This information does not reveal your specific identity (like your name or contact information) but may include device and usage information, such as your IP address, browser and device characteristics, operating system, language preferences, referring URLs, device name, country, location, information about how and when you use our Services or Apps and other technical information. This information is primarily needed to maintain the security and operation of our Services or Apps, and for our internal analytics and reporting purposes.
Information collected through our Apps
In Short: We may collect information regarding your geo-location, push notifications, when you use our apps.
If you use our Apps, we may also collect the following information:
HOW CAN YOU REVIEW, UPDATE, OR DELETE THE DATA WE COLLECT FROM YOU?
Based on the laws of some countries, you may have the right to request access to the personal information we collect from you, change that information, or delete it in some circumstances. To request to review, update, or delete your personal information, please submit a request form. We will respond to your request within 30 days.
You may not access or use the Site for any purpose other than that for which we make the Site available. The Site may not be used in connection with any commercial endeavors except those that are specifically endorsed or approved by us.
As a user of the Site, you agree not to:
1. Systematically retrieve data or other content from the Site to create or compile, directly or indirectly, a collection, compilation, database, or directory without written permission from us.
2. Make any unauthorized use of the Platform Offerings, including collecting usernames and/or email addresses of users by electronic or other means for the purpose of sending unsolicited email, or creating user accounts by automated means or under false pretenses.
3. Use a buying agent or purchasing agent to make purchases on the Site.
4. Use the Site to advertise or offer to sell goods and services.
5. Circumvent, disable, or otherwise interfere with security-related features of the Site, including features that prevent or restrict the use or copying of any Content or enforce limitations on the use of the Site and/or the Content contained therein.
6. Engage in unauthorized framing of or linking to the Site.
7. Trick, defraud, or mislead us and other users, especially in any attempt to learn sensitive account information such as user passwords.
8. Make improper use of our support services or submit false reports of abuse or misconduct.
9. Engage in any automated use of the system, such as using scripts to send comments or messages, or using any data mining, robots, or similar data gathering and extraction tools.
10. Interfere with, disrupt, or create an undue burden on the Site or the networks or services connected to the Site.
11. Attempt to impersonate another user or person or use the username of another user.
12. Sell or otherwise transfer your profile.
13. Use any information obtained from the Site in order to harass, abuse, or harm another person.
14. Use the Platform Offerings as part of any effort to compete with us or otherwise use the Site and/or the Content for any revenue-generating endeavor or commercial enterprise.
15. Decipher, decompile, disassemble, or reverse engineer any of the software comprising or in any way making up a part of the Site.
16. Attempt to bypass any measures of the Site designed to prevent or restrict access to the Site, or any portion of the Site.
17. Harass, annoy, intimidate, or threaten any of our employees or agents engaged in providing any portion of the Platform Offerings to you.
18. Delete the copyright or other proprietary rights notice from any Content.
20. Upload or transmit (or attempt to upload or to transmit) viruses, Trojan horses, or other material, including excessive use of capital letters and spamming (continuous posting of repetitive text), that interferes with any party’s uninterrupted use and enjoyment of the Site or modifies, impairs, disrupts, alters, or interferes with the use, features, functions, operation, or maintenance of the Platform Offerings.
21. Upload or transmit (or attempt to upload or to transmit) any material that acts as a passive or active information collection or transmission mechanism, including without limitation, clear graphics interchange formats (“gifs”), 1×1 pixels, web bugs, cookies, or other similar devices (sometimes referred to as “spyware” or “passive collection mechanisms” or “pcms”).
22. Except as may be the result of standard search engine or Internet browser usage, use, launch, develop, or distribute any automated system, including without limitation, any spider, robot, cheat utility, scraper, or offline reader that accesses the Site, or using or launching any unauthorized script or other software.
23. Disparage, tarnish, or otherwise harm, in our opinion, us and/or the Site.
24. Use the Site in a manner inconsistent with any applicable laws or regulations.
If we terminate or suspend your account for any reason, you are prohibited from registering and creating a new account under your name, a fake or borrowed name, or the name of any third party, even if you may be acting on behalf of the third party. In addition to terminating or suspending your account, we reserve the right to take appropriate legal action, including without limitation pursuing civil, criminal, and injunctive redress.
We reserve the right to change, modify, or remove the contents of the Site at any time or for any reason at our sole discretion without notice. However, we have no obligation to update any information on our Site. We also reserve the right to modify or discontinue all or part of the Platform Offerings without notice at any time. We will not be liable to you or any third party for any modification, price change, suspension, or discontinuance of the Site or the Platform Offerings.
THE SITE AND THE PLATFORM OFFERINGS ARE PROVIDED ON AN AS-IS AND AS-AVAILABLE BASIS. YOU AGREE THAT YOUR USE OF THE SITE AND OUR SERVICES WILL BE AT YOUR SOLE RISK. TO THE FULLEST EXTENT PERMITTED BY LAW, WE DISCLAIM ALL WARRANTIES, EXPRESS OR IMPLIED, IN CONNECTION WITH THE SITE AND THE PLATFORM OFFERINGS AND YOUR USE THEREOF, INCLUDING, WITHOUT LIMITATION, THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, AND NON-INFRINGEMENT. WE MAKE NO WARRANTIES OR REPRESENTATIONS ABOUT THE ACCURACY OR COMPLETENESS OF THE SITE’S CONTENT OR THE CONTENT OF ANY WEBSITES LINKED TO THE SITE AND WE WILL ASSUME NO LIABILITY OR RESPONSIBILITY FOR ANY (1) ERRORS, MISTAKES, OR INACCURACIES OF CONTENT AND MATERIALS, (2) PERSONAL INJURY OR PROPERTY DAMAGE, OF ANY NATURE WHATSOEVER, RESULTING FROM YOUR ACCESS TO AND USE OF THE SITE, (3) ANY UNAUTHORIZED ACCESS TO OR USE OF OUR SECURE SERVERS AND/OR ANY AND ALL PERSONAL INFORMATION AND/OR FINANCIAL INFORMATION STORED THEREIN, (4) ANY INTERRUPTION OR CESSATION OF TRANSMISSION TO OR FROM THE SITE OR THE PLATFORM OFFERINGS, (5) ANY BUGS, VIRUSES, TROJAN HORSES, OR THE LIKE WHICH MAY BE TRANSMITTED TO OR THROUGH THE SITE BY ANY THIRD PARTY, AND/OR (6) ANY ERRORS OR OMISSIONS IN ANY CONTENT AND MATERIALS OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRED AS A RESULT OF THE USE OF ANY CONTENT POSTED, TRANSMITTED, OR OTHERWISE MADE AVAILABLE VIA THE SITE. WE DO NOT WARRANT, ENDORSE, GUARANTEE, OR ASSUME RESPONSIBILITY FOR ANY PRODUCT OR SERVICE ADVERTISED OR OFFERED BY A THIRD PARTY THROUGH THE SITE, ANY HYPERLINKED WEBSITE, OR ANY WEBSITE OR MOBILE APPLICATION FEATURED IN ANY BANNER OR OTHER ADVERTISING, AND WE WILL NOT BE A PARTY TO OR IN ANY WAY BE RESPONSIBLE FOR MONITORING ANY TRANSACTION BETWEEN YOU AND ANY THIRD-PARTY PROVIDERS OF PRODUCTS OR SERVICES. AS WITH THE PURCHASE OF A PRODUCT OR SERVICE THROUGH ANY MEDIUM OR IN ANY ENVIRONMENT, YOU SHOULD USE YOUR BEST JUDGMENT AND EXERCISE CAUTION WHERE APPROPRIATE.
IN NO EVENT WILL WE OR OUR DIRECTORS, EMPLOYEES, OR AGENTS BE LIABLE TO YOU OR ANY THIRD PARTY FOR ANY DIRECT, INDIRECT, CONSEQUENTIAL, EXEMPLARY, INCIDENTAL, SPECIAL, OR PUNITIVE DAMAGES, INCLUDING LOST PROFIT, LOST REVENUE, LOSS OF DATA, OR OTHER DAMAGES ARISING FROM YOUR USE OF THE SITE OR THE PLATFORM OFFERINGS, EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. NOTWITHSTANDING ANYTHING TO THE CONTRARY CONTAINED HEREIN, OUR LIABILITY TO YOU FOR ANY CAUSE WHATSOEVER AND REGARDLESS OF THE FORM OF THE ACTION, WILL AT ALL TIMES BE LIMITED TO THE LESSER OF THE AMOUNT PAID, IF ANY, BY YOU TO US DURING THE SIX (6) MONTH PERIOD PRIOR TO ANY CAUSE OF ACTION ARISING OR __________. CERTAIN US STATE LAWS AND INTERNATIONAL LAWS DO NOT ALLOW LIMITATIONS ON IMPLIED WARRANTIES OR THE EXCLUSION OR LIMITATION OF CERTAIN DAMAGES. IF THESE LAWS APPLY TO YOU, SOME OR ALL OF THE ABOVE DISCLAIMERS OR LIMITATIONS MAY NOT APPLY TO YOU, AND YOU MAY HAVE ADDITIONAL RIGHTS.
Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration administered by the [______] under its [Commercial Arbitration Rules/Healthcare Payor Provider Rules/Rules of Procedure for Arbitration by the American Health Lawyers Association]. The number of arbitrators shall be one. The place of arbitration shall be located in the state of Delaware. Delaware law shall apply. Judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. The costs of arbitration will be split evenly between the Clinician and Science.