You Must Read the Following and Agree to All Terms and Conditions.
By Closing and Continuing You are Acepting this Agreement

PATIENT CONSENT TO TREATMENT AND RELEASE AGREEMENT

By creating this membership with ConsultsDirect.net for the purpose of requesting telemedicine consultation(s) with contracted health care providers assigned to me by ConsultsDirect.net, I understand and agree to the following:

1. I understand that Consults Direct operates as a “covered entity” (specifically a “health Care Clearinghouse”), in accordance with the health Information Portablility and Accountablility Act (HIPAA) of 1996, to receive and format non-standard health information and to facilitate coordination and billing for telemedicine services.(See http://www.hipaa.org/)

2. I give my permission to ConsultsDirect.net and their medical partners to review my medical history to include the medical history questionaire, photo identification form, medical records which I provided and physical exam form signed by my PCP. After all documents are received and your notarized PCP Notice Agreement is received your documents will be forwarded to our medical staff for review prior to consult. You acknowledge and understand that after reviewing these documents you may not be considered a suitable candidate for treatment at which time you will be billed for an administrative fee of $25 for the costs incurred for processing your medical profile but will not be charged for the consultation. At that time you will be refunded the $195 less the $25 processing fee. ($170) *We do provide Overnight/COD Service for an additional fee.

3. By submitting my medical records and history for review for a consultation and possible prescription(s), I agree to release from liability and hold harmless Consults Direct, their affiliates, directors, employees, officers, representatives, subsidiaries, and independent contractors from all causes of action, law suits, penalties, liens, judgments, liabilities, obligations, losses, actual or consequential damages, actual or threatened claims which may arise at any time by reason of, relating to, arising directly or indirectly out of any matter whatsoever related to the prescription of medication.

4. This consultation is being submitted by my own accord, at my own expense, and my own liability and I assume all responsibility for the use of treatments prescribed by Consults Direct. I fully understand that it is my responsibility to have an annual physical examination, including any suggested laboratory tests, to ensure that I have no disease that might be incompatible for your described condition or your physician diagnosed condition. I also agree to immediately notify any doctor whose present care I am under that I have chosen to take a prescription facilitated by Consults Direct so that they may advise to continue or discontinue use. Should I engage a new doctor's care in the future; I further agree to immediately notify said doctor of my use of treatments facilitated by Consults Direct.

5. I hereby release Consults Direct and all of their employees and contractors including physicians and pharmacists from any and all liability whatsoever associated or connected with your consultation and/or your use of treatments prescribed. I hereby state that I am of the age twenty five (25) or older. I understand that falsifying information in order to obtain prescription medication is a violation of both State and Federal US law. I hereby agree to answer truthfully all of the medical questions on the questionnaire.

6. I understand that no doctor, nurse, or administrative personnel can guarantee that I will gain any lasting benefit from said treatments, even if prescribed, and it may not give me the results I seek. However, I understand that even if prescribed, I may suffer adverse effects from treatments. I hereby release Consults Direct and all of its contractors and employees to include physicians and pharmacists from any and all liability whatsoever associated with any adverse effects you may suffer from my use of prescribed treatments. I understand that it is my responsibility to furnish Consults Direct with my complete and accurate medical history and follow up thereafter with any changes to it which occurs at a subsequent time.

7. I understand that the proposed consultation and care may involve risks and possibilities of complications and that certain complications or side effects have been known to occur in patients who take prescribed treatments even when the utmost care, judgment, and skill are used. You acknowledge that no guarantees have been made to you as to the results or are there any guarantees against favorable results, risks, or complications.

8. I understand and agree that Consults Direct and its employees may forward any information you provide to your physician and that such information will constitute a medical record. I further understand and agree that Consults Direct, my physician, or both will maintain my medical records. I also understand that Consults Direct is required by law to maintain and protect your personal records including health care information, personal information, and billing information (See http://www.hipaa.org/)

9. I understand and acknowledge that Consults Direct and its physicians REQUIRE A PHYSICAL EXAMINATION WITHIN THE PAST 12 MONTHS BY A DOCTOR BEFORE I WILL BE CONSIDERED FOR TREATMENTS BY Consults Direct. I also will ATTEST that the medical condition or complaint that I am describing is true and that the condition may be defined as an “Emergency Medical Situation.” An Emergency Medical Situation” may be defined as “a condition of emergency in which immediate medical care or hospitalization, or both, is required by a person or persons for the preservation of health.” This definition may be modified in meaning and or definition to constitute the definition of a “Temporary Health Care Provider-Patient Relationship” in the state in which you reside and/or the doctor resides, is licensed and or practices medicine.

10. I understand that during my consultation, Consults Direct health care provider will expressively communicate all potential side effects of a treatment or medication being prescribed, and that additional prescribing information will accompany my prescription(s), but it is not possible for all the potential side effect(s) of a medication to be known. I understand that the potential side effects and complications that are communicated to me are highly predicated upon the information that I provided to Consults Direct verbally, in writing, and via electronic submission online and by fax submission including my Patient Medical History Questionnaire/Patient Physical examination form and my medical records.

11. I acknowledge and agree that I initiated the contract with Consults Direct and its physicians. I also know that they may not be in the state that I reside but may be located in another state or country from my own and that the Physician may NOT be licensed to practice medicine in my state of residence.

12. I agree and fully understand that all medical consultations, diagnoses, and treatments will be deemed to have occurred in the state where the physician is physically located and licensed to practice medicine.

13. I fully understand and agree that if I fail in any way to furnish Consults Direct with my complete and accurate medical history, or I become aware of any changes in my physical or medical condition in the future and I fail to notify Consults Direct or its physicians of such changes, then I agree that I am solely responsible for any adverse effects I may suffer from taking or continuing to take treatments prescribed by the physicians affiliated with Consults Direct or from participating in this program.

14. Refunds will be given on a case by case basis.

15. I understand and agree that I are responsible for all customs, tariffs, and taxes, if applicable, in your state. And any shipping and handling fees.

16. I understand that I will be responsible for dropping off and picking up my prescription from my designated pharmacy.

17. I understand that if I am approved, I will be given a prescription with my consult. I also understand it is my responsibility to call 10 days prior to a new refill for a subsequent consultation.

18. I understand and acknowledge that there is no implied warranty. I understand that treatments vary from patient to patient. I understand that there is no known medical treatment that gives 100% satisfaction to everyone. I understand that Consults Direct provides contracted adjunctive telehealth services intended to supplement the traditional health care that you receive from your primary care physician and that the services administered by Consults Direct health care providers are not intended to diagnose new health problems.

19. The information on the Site may include inaccuracies or typographical errors and are subject to change at any time. All information provided is "as is" without warranty of any kind.

20. I agree and understand that the quality of this service and longevity of this industry will rely solely on following state and country FDA guidelines. Consults Direct believes that by using Consults Direct’s program where by using your local pharmacy that this should cut down on issues that have in the past posed a problem using out of state pharmacies. I realize that being both patient and courteous while the process is working makes things move smoother. My general understanding of this service is that I will be responsible for getting my records faxed in a timely manner. I understand once I have given all documents needed and Consults Direct received my money order the next step will my medical profile will be reviewed by the PA and if all is complete forwarded to the doctor. The PA in turn will then call me at a prearranged time for a personal telephone consult, and recommend to a doctor for scripting. The doctor will then review all records and give his approval. If successful, he will write a prescription and send it to CD. CD will then send it to your desired location via FEDEX. I also understand that I will be responsible for filling the prescription along with any refills at my local pharmacy. I also understand that when it is time to get a new refill I will need to contact Consults Direct at least 10 days prior to expiration to schedule a new consult. I also understand that the pharmacy may call for verification and the doctor returns calls after 5:00 PM

21. I have read and understood the above-referenced provisions and authorize and accept the proposed terms and care regardless of the medical or legal risks and declare that I understand the risks.

22. I further understand and agree that by accepting or rejecting the terms of this “consent to medical care” by electronically making my choice below. If I select “I agree”, I acknowledge that such choice will constitute the equivalent of my signature upon a binding agreement between Consults Direct and myself.