Consent Form

  • I understand that I am choosing to engage in a telehealth consultation utilizing the MediOrbis platform through its physician network MySpecialistMD Network ("MO/MSMDNet").
  • I understand that "telehealth" can include the practice of healthcare delivery, monitoring, diagnosis, consultation, treatment, prescriptions, laboratory examinations, follow up care, transfer of medical data as well as education using a software technology platform that can facilitate interactive or asynchronous audio, video, chat and other data communication modalities
  • I understand and agree to receive transactional and engagement messages related to my telehealth consultations, including appointment confirmations, reminders, updates from the healthcare provider and other essential communication via email, SMS or secure messaging within the platform.
  • I understand that this also involves communicating and disclosing my medical information to the healthcare practitioners and their support team members to facilitate accurate diagnosis and effective treatment.
  • I am aware that the telehealth consultation will be conducted via electronic communication unlike the traditional in-person visit to the healthcare provider, and that MO/MSMDNet has facilitated the use of a telehealth platform which will be used to enable such a consultation.

  • Intended Benefits:
    - Access to care from a location of your choosing
    - More efficient care delivery

    Possible Risks:
    - Diagnostic limitations due to lack of physical examination
    - Technology or communication disruptions or failures, including phone, cellular or internet interruptions, unauthorized access and technical difficulties
    - An inability to treat urgent or emergent conditions in person

  • I understand that there are risks and benefits associated with any form of medical treatment and that despite the efforts of my provider, my condition may not improve, and in some cases, can even worsen. Therefore, I understand that although I may benefit from telehealth services, the results cannot be guaranteed or assured.
  • I understand that either the provider or I can discontinue the telehealth consultation or visit at any time if it is sensed or determined that it may not be adequate to address the situation, or for any other reasons.
  • I have had the alternatives to the telehealth consultation explained to me, and in choosing to participate in a telehealth consultation, I understand that some aspects of physical examination cannot be conducted via telehealth platforms or may need to be carried out by individuals in my location under the supervision of the consulting provider. The provider will use their best judgment in determining whether any such examinations are required and how to carry them out. Despite this limitation, I wish to proceed with the telehealth consultation
  • I further understand that I have the right to request:
    - The omission of specific details of my medical history/physical examination that are sensitive to me
    - Termination of the consultation at any time
  • In an emergent consultation, I understand that the responsibility of the telehealth consulting provider is to refer me to my local practitioner, and that the provider's responsibility will conclude upon the termination of the telehealth consultation.
  • I understand the risks, benefits, and any practical alternatives associated with the telehealth consultation. I have been given the opportunity to ask questions, obtain clarifications, as well as to consult with others about this process before making my decision.

  • For international patients: I understand that as a patient from the EU, my rights under the General Data Protection Regulation (GDPR) compliance law, grant me the ability to review, change, or terminate my patient account at any time. I further understand that in specific regions, such as the European Economic Area, patients have greater control to protect personal health information. Patients therefore have unique rights under applicable data protection laws.
    These may include the right:
    i) to request access and obtain a copy of the personal health information;
    ii) to request rectification or erasure;
    iii) to restrict the processing of personal health information; or
    iv) if applicable, to data portability

    Note: To make any such request, please contact support at 1-866-MEDIORB or support@mediorbis.com.
    MediOrbis and the MSMD Network will consider and act upon requests in accordance with applicable data protection laws.

    Consent terms in case of minors: As a parent or legal guardian, I consent to my minor child's telehealth visit and agree to the above mentioned terms and conditions, including the risks, benefits and privacy protections involved.

    I do hereby certify that:

      I have read the consent form or have had it read and explained to me.

      I fully understand the above mentioned terms and conditions, including the risks and benefits associated with telehealth consultation.

      I have been given ample opportunities to ask questions and that all my doubts have been clarified to my satisfaction.