I consent to receive healthcare services through asynchronous telehealth. I understand this method involves electronic communication, including consultations, potential diagnoses, and treatments, but does not include a physical medical examination.

 I acknowledge that my provider may determine telehealth is not suitable for my specific condition. I also understand there is no assurance I will receive a prescription or particular treatment, as these decisions depend on the provider's professional judgment.

 I understand that I can withdraw my consent for telehealth at any time without impacting my access to future care, as long as I comply with the applicable terms of service.

 I acknowledge that Dr. Katina Health and Wellness, Inc. implements security measures to protect sensitive information, such as:
   ○ Physical safeguards for network systems to restrict access to authorized personnel.
   ○ Rules limiting physical access to locations where sensitive data, including PHI (Protected Health Information) and PII (Personally Identifiable Information), are stored.
   ○ Secure procedures for disposing of media containing sensitive data to prevent unauthorized access.

 I understand that a healthcare provider will be assigned to me, and I have the right to review their credentials.

 I recognize that telehealth services are optional and offer benefits such as convenience and quick access to care. However, I also understand the potential risks, including:
   ○ The lack of in-person interactions with my provider.
   ○ Possible data security breaches.
   ○ Limited access to my complete medical history, which could affect treatment decisions.

 I acknowledge that in-person care is an alternative to telehealth and that some conditions may not be appropriate for telehealth services. I also understand that telehealth may not suit all individuals, and some patients may prefer in-person care.

 In case of a medical emergency, I understand that I must call 911 or go to the nearest emergency room. I will not use the asynchronous consultation platform of Dr. Katina Health and Wellness, Inc. for emergency services.

 I agree to inform my provider if I have recently sought emergency medical attention.

By submitting this form you agree to the terms of the Privacy Policy.