Texas Herbal Clinic
Informed Consent For Telemedicine Medical Services
1. Introduction: Please read this document thoroughly and completely. To better serve the needs of the community, especially in light of the Coronavirus pandemic, health care services are now available using telecommunications or information technology (“Telemedicine”). Telemedicine involves the use of real-time evaluation, diagnosis, consultation, and treatment of health conditions using interactive telecommunications technology allowing the health care provider to see and communicate with you in real-time.
2. Consent for Treatment: You have voluntarily requested that Dr. Darryl Camp, MD participate in your medical care using Telemedicine. In doing so, you understand, acknowledge and agree to the following:
- a. The health care provider may practice in a location different than where you normally go to receive in-person medical care.
- b. Unlike traditional medicine, the health care provider providing the Telemedicine services will not have the opportunity to meet with you face to face.
- c. The health care provider providing the Telemedicine services must rely on the information you provide.
- d. To the best of your ability, you agree to provide complete and accurate information concerning your medical history, condition and care as may be requested by the health care provider.
- e. You understand that if the health care provider feels that your medical needs cannot be adequately addressed using Telemedicine, you may be required to seek an in-person evaluation.
- f. You understand you can stop your Telemedicine session at any time.
- g. You understand you can ask questions or seek clarifications of the Telemedicine procedures and technology at any time.
- h. You understand that no guarantee of any specific result or cure is made by the health care provider rendering the Telemedicine services.
- i. If you experience an emergency after the Telemedicine session, you should alert your primary treating physician and dial 911 or go to the nearest emergency department.
3. Risks. You agree and acknowledge that there are potential risks associated with receiving medical care using Telemedicine:a. The Telemedicine session may be interrupted or disconnected due to a technological problem or equipment failure.b. There may be electronic tampering.c. The advice provided by the health care provider may be based on factors not within his/her control, such as incomplete or inaccurate information provided by you or distortions of diagnostic images or specimens due to their electronic transmission.
4. NOTICE CONCERNING COMPLAINTS. While we hope all patients are happy with the Telemedicine services they receive, you have a right to make a verbal or written complaint. If you have comments, questions or concerns, please contact us.
Telemedicine Consent Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists.
Texas Medical Board
Attn: Investigations
333 Guadalupe, Tower 3, Suite 610
P.O. Box 2018, MC-263
Austin, TX 78768-2018
Assistance in filing a complaint is available by calling the following telephone number: 1- 800-201-9353. For more information on filing a complaint with the Texas Medical Board, visit the Texas Medical Board website at www.tmb.tx.us