Informed Consent for Telehealth Services Through
the Slimbody Platform

Last modified August 1, 2024
Telehealth involves the provision of health care services through use of electronic communications to enable a health care provider at one location to provide care to a patient located at a different location. The telehealth services made available through the SlimbodyPlatform are provided by independent, licensed providers (the “Providers”), and may typically include, without limitation, chart review, remote prescribing, interactive audio or audio-visual consultations, medication management, laboratory services, and health information sharing (including care coordination with your other treating providers).
The Slimbody Platform incorporates network and software security protocols to protect the confidentiality of patient data and includes measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
The 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.

Expected Benefits of Telehealth Services:

  • Improved access to care by enabling you to remain in your home while the Provider consults and obtains test results at distant / other sites.
  • More efficient care evaluation and management.
  • Obtaining expertise of a specialist as appropriate.

Possible Risks Associated with Telehealth Services:

  • Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
  • In rare events, the Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with a local provider.
  • In rare events, a lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgment errors.
  • In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
If you need to receive follow-up care or assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact your Provider.
By signing this form, you acknowledge that you understand and agree with the following:
  • I hereby consent to receiving the telehealth services made available through the SlimbodyPlatform.
  • I understand that the telehealth services made available through the Slimbody Platform do not replace the relationship between me and my primary care provider or any other health care provider with whom I have a practitioner-patient relationship.
  • I understand it is up to the Provider to determine whether my specific clinical needs are appropriate for a telehealth encounter. If, in the professional judgment of my Provider, I am not appropriate for telehealth-based care, I understand that I will be notified and instructed to find an in-person service which may be more appropriate for me.
  • I understand that, in the delivery of services to me, the Provider will rely on all information I provide as accurate and complete. I further understand that the inaccuracy of any such information I provide may impact the efficacy of such services. I understand that I have a duty to answer questions about my health and medical history honestly and accurately, and to keep all of my health care providers, including my Provider, up-to-date on any changes in my health, symptoms, treatments, or medications.
  • I understand the Provider will provide me with information related to my diagnosis, treatment, and ongoing care, and that the success of my treatment and care is dependent upon my review of this information. I agree to review all such information the Provider shares with me.
  • I understand that federal and state laws require health care providers to protect the privacy and security of health information. I understand that the Provider will take steps to make sure that my health information is not seen by anyone who should not see it.
  • I understand there is a risk of technical failures during the telehealth encounter beyond the control of Slimbody and the Provider. I agree to hold harmless Slimbody and the Provider for delays in evaluation or for information lost due to such technical failures.
  • I understand that I have the right to withdraw my consent to the use of telehealth in the course of my care at any time. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
  • I understand that I may expect the anticipated benefits from the use of telehealth services in my care, but that no results can be guaranteed or assured.
  • I understand that my health information may be shared with other individuals for scheduling and billing purposes.
  • I understand that persons other than the Provider may be present during the telehealth services in order to operate the telehealth technologies. I further understand that I will be informed of the presence of such individuals and that I will have the right to request any or all of the following: (1) to omit specific details of my medical history / examination that are personally sensitive to me; (2) to ask non-medical personnel to leave the room during the course of the telehealth examination; and/or (3) to terminate the telehealth examination at any time.
  • 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 by the Provider.
  • I understand there may be side effects from certain medications prescribed, and that my Provider will specifically address these risks when prescribing such medication to me.
  • I understand that the telehealth services made available to me through the SlimbodyPlatform are not intended to handle medical emergencies. If I have an emergency that needs immediate response, I agree that I will call 911 or go to my nearest emergency room.

    Consent

    I have read this document carefully and understand the risks and benefits of the telehealth consultation, and I have had my questions regarding the consultation explained. I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.
    This authorization is effective beginning: ___/___/___.
    Patient Signature: ______________________________________
    Patient Name: _____________________________________________
    Patient Date of Birth: ________________________________________