Informed Consent to Teledermatology Treatment Services
Last Updated: Feb 12, 2021
This Informed Consent to Teledermatology Services is for the undersigned’s (“you”, “I” or “your”) receipt of teledermatology services (the “Services”) from Docent Medical Corp available through a technology platform offered by Docent Medical Corp. and its affiliates, including Docent, Inc. (the “Platform”). The Services involve the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of providing and improving patient care. The Services may include remote prescribing, health information sharing, and non-clinical services, such as patient education.
The Platform 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.
Docent Medical Corp will send you email correspondence that may contain details of your treatment. These emails will never contain your photos or payment information. We will never request that you email us any health information or payment information.
Docent Medical Corp providers (our "Providers") are an addition to, and not a replacement for, your primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not. Before you give your consent to request Services, please be aware of how receiving care through our Platform differs from an in-person visit with your primary care provider or dermatologist for the same care. If you have any questions, please contact us.
Provider(s) will be interacting with you solely via use of the Platform. As a result, all of the medical care and treatment you receive from such Providers will be provided via teledermatology, and you will not be able to meet with your Provider in a physical location. You will be provided with the name, credentials, licensure/certification, and qualifications of the Provider who will be providing your care. You may contact your Provider(s) for follow-up questions by sending a message to your Provider(s) via our member portal in the Platform. Your Provider will respond at his or her earliest convenience. However, a Provider should not be contacted in the case of a medical emergency, as noted below.
For additional questions you may contact us via the Platform or via email at firstname.lastname@example.org.
Persons under the age of 18 are prohibited from using our Services. If you are a parent or guardian of an individual under the age of 18 and believe your child has disclosed personal or health information to Docent without your authorization, please contact us at email@example.com.
- Improved access to care by enabling you to remain in your home while you receive Services.
- More efficient care evaluation and management.
- Access to the expertise of a dermatologic specialist, as appropriate.
- Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
- In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating additional teledermatology interactions or a meeting with your local primary care doctor.
- The electronic nature of the Services means that there is a greater risk to the privacy of your electronic health information relative to visiting a health center.
- In very rare events, security protocols could fail or technical failures may occur, causing a loss of data or information, or a breach of privacy of personal medical information.
- The health information you provide may be the only source of health information used by the Provider(s) during the provision of Services, and such Provider(s) may not have access to additional medical records or information. In rare events, a lack of access to complete information or medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
- The inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency care.
- Your Provider will NOT be familiar with or have access to available medical resources, including emergency resources, near your location. They will NOT be able to make a suitable local referral where medically indicated.
- The Platform is not intended to be used for medical emergencies. In the case of a medical emergency, you should dial 9-1-1, go to your nearest urgent care center or emergency room, or contact your local emergency assistance services immediately.
By checking the box associated with "Informed Consent", you acknowledge that you understand, agree with, and consent to the following:
- I hereby consent to receiving Docent Medical Corp’s services via teledermatology technologies. I understand that Docent Medical Corp and its Providers offer teledermatology-based medical services, but that these services do not replace the existing relationship between me and my primary care doctor or dermatologist. I also understand it is up to the Provider(s) to determine whether or not my specific clinical needs are appropriate for a teledermatology encounter.
- I understand that Providers reserve the right to deny treatment if they believe that a patient may be better served by a local provider, or for any other reason according to their professional judgment.
- I consent to Docent Medical Corp providing copies of my medical records to my primary care physician for Services rendered through the Platform. I will provide Docent Medical Corp with the name of my primary care physician through the Platform if and when I request that Docent Medical Corp provide such copies of my medical records to my primary care physician.
- I understand that Docent Medical Corp and Providers operate subject to state regulation and may not be available in certain states.
- I understand that Docent Medical Corp is exclusively for the diagnosis and treatment of acne and skin aging (and related conditions), and not for any other medical or dermatological conditions. I understand that Providers do not provide screening for skin cancer or for any other conditions aside from acne and skin aging.
- I certify that all of the information I will provide to Provider(s) must be true, accurate, and complete. I understand that if I knowingly provide false, misleading, or incomplete information to a medical professional, I may not be able to receive further Services.
- I understand I should ask questions about anything I do not understand by sending a message. I understand I must check the Platform regularly for messages in order to communicate with Providers, and that if I do not my care and treatment may be delayed.
- I understand that I may expect the anticipated benefits from the use of teledermatology in my care, but that no results can be guaranteed or assured.
- I understand that I have the right to withhold or withdraw my consent to the use of teledermatology in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the teledermatology services at any time for any reason or for no reason.
- I understand that if I participate in a consultation, that I have the right to request a copy of my medical records by contacting us via the Platform, which will be provided to me at reasonable cost of preparation, shipping and delivery.
- I understand that if I would like to have my records sent to my primary care provider or dermatologist, I must request such transfer of records by contacting us via the Platform, which will be transferred at reasonable cost of preparation, shipping and delivery.
- I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Docent Medical Corp will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that teledermatology may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state as well as with certain other third parties. This includes information provided with other individuals for communication, billing, or other appropriate internal business purposes. I understand, agree, and expressly consent to Docent Inc. obtaining, using, storing, and disseminating to necessary third parties, information about me and my image, as necessary to provide Services through the Platform.
- I understand there is a risk of technical failures during the teledermatology encounter beyond the control of Docent Medical Corp. I agree to hold harmless Docent Medical Corp and Docent Inc for delays in evaluation or for any loss of data or information due to such technical failures.
- I understand that all customized prescription medications are produced and shipped by licensed professionals directly to patients. I understand I can also choose to fill my prescription at a pharmacy of my choice.
- I understand that I will need to pay for Services received through the Platform myself and that Docent Medical Corp does not accept any insurance or other third party payments. I understand that by using this Platform, I are freely electing to pay out of pocket for all Services and prescriptions provided through the Platform and that I may be foregoing discounts or insurance coverage that would otherwise be available to me if I sought care in-person. I understand that it is my responsibility to arrange and pay for any follow-up care that Docent Medical Corp recommends I receive. I further understand that Docent Medical Corp does not cover the cost of any prescription pills that may be prescribed in addition to my customized prescription cream.
- I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.
- I understand that Docent Medical Corp’s Services are not an insurance product.
- I understand that Docent Medical Corp is not for emergencies. I understand that if I am experiencing a medical emergency, that I should dial 9-1-1 immediately and that the Providers are not able to connect me directly to any local emergency services.
I have read this document carefully and understand the risks and benefits of the teledermatology consultation and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in a teledermatology consultation, and further permit Provider(s) to examine, consult, diagnose, or treat me under the terms described herein. I understand this informed consent will become a part of my medical record.