Consent Form

GENERAL CONSENT

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that:

1. You consent to any and all health care treatment and diagnostic procedures provided by Lakeside Care Clinic, its associated clinicians, and other personnel.
2. You consent to the use and disclosure of my (the patient's) protected health information for purposes of obtaining payment for services rendered, treatment, and health care operations consistent with the Lakeside Care Clinic Notice of Privacy Practices.
3. You give permission to obtain all of your medication/prescription history when using an electronic system to process prescriptions for your medical treatment.
4. You have provided, to the best of your ability, information that is accurate regarding medical and surgical history, current and previous medications and/or treatments, current or past substance use, and current patient- provider relationships.
   

You have the right to discuss the treatment plan with your provider about the purpose, potential risks and benefits of any test ordered for you. You have the right at any time to refuse any procedure or treatment and/or to discontinue services. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions.

TELEHEALTH CONSENT

I hereby authorize Lakeside Care Clinic to use the telehealth platform, where appropriate, for evaluating, testing, and diagnosing my medical condition. I understand that while telehealth has been found to be effective in treating a wide range of conditions, there is no guarantee that telehealth is safe or effective for all individuals or situations. Providers are not able to perform a true physical exam, check vital signs, or take other actions that are part of the standard of care for the prescription of certain medications or the management of certain conditions. If my provider makes recommendations for me to take actions to mitigate risks of adverse outcomes, it is my responsibility to do so, and I acknowledge that not doing so may result in harm or an adverse outcome.

I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended. I accept that the professionals can conduct interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

I understand that Lakeside Care Clinic uses telehealth technology designed to protect my privacy, but acknowledge that electronic medical communications carry some level of risk for accidental disclosures such as hacking or interceptions. I understand that there is a risk of being heard by people near me and that I am responsible for using a location that is private and free from distractions or intrusions. I agree that my medical records from telehealth visits can be kept for further evaluation, analysis, and documentation, and in all of these, my information will be kept private.

I understand that my current insurance may not cover the cost of visits conducted via telehealth or additional fees of the telehealth practices, and I acknowledge that I will be responsible for any fee that my insurance company does not cover.

Patient Signature ____________________________________________________________
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Date ____________________________________

Relationship to Patient _______________________________________________________