Z Medi Clinics and Z Medi Spa

Informed Consent for Telemedicine Services

Introduction 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. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files 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.

Expected Benefits: 

• Improved access to medical care by enabling a patient to remain in his/her home (or at a remote site) while the physician/provider obtains test results and consults from healthcare practitioners at distant/other sites.
• More efficient medical evaluation and management.
• Obtaining expertise of a distant specialist.

Possible Risks: As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;

1. I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent and authorize ZMed Clinic and Z MEDI CLINIC Providers, PA to use telemedicine in the course of my diagnosis and treatment.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in my care at any time, without affecting my right to future care or treatment, 3. I understand that I have the right to inspect all information obtained and recorded in the course of telemedicine interaction, and may receive copies of this information for a reasonable fee,
3. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. The alternatives to telemedicine have been explained to me.
4. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
5. I understand that it is my duty to inform ZMed Clinic and Z Medi Clinic Providers, PA of electronic interactions regarding my care that I may have with other healthcare providers. 7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
6. I attest that I am located in the State of Texas and will be present in the State during all telemedicine encounters with ZMed Clinic and ZMedi Clinic Providers, PA. Patient Consent To The Use of Telemedicine I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care. I hereby authorize ZMed Clinic and Z MEDI CLINIC Providers, PA to use telemedicine in the course of my diagnosis and treatment.

If you would like your username and password, please ask a staff member for the information. Please provide us with your secure email address.

I understand that Blood work is required every 6 months. I also, understand that I will have to physically be seen in the Z-Med Clinic  at that time that the blood work is due. To be eligible to continue the Telemedicine/Healow visits in the future. We ask that you please have good internet access at the time of your Telemedicine/Healow visit. If unable to connect to the Healow App (successful) we will ask that you schedule an in office appointment. Payment is due at the time of the Telemedicine/Healow appointment. Please have your Card/Payment Information ready, along with your pharmacy information at the time of your future Telemedicine/Healow Visits.