I ____________________________________________, consent to engaging in tele-health with Texas Medical Concierge as a part of the therapy process and my treatment goals. I understand that tele-health services may include mental health evaluation, assessment, consultation, treatment planning, and therapy. Telehealth will occur primarily through interactive audio and video communications. By signing this consent, I am verifying that I understand the following:

  1. I have the right to withhold or remove consent for tele-health services at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.
  2. The laws that protect the confidentiality of my personal information also apply to tele-health. As such, I understand that the information released by me during the course of my sessions is confidential, just as it would be if I were in the clinic. I understand that the visit is transmitted over dedicated lines and cannot be accessed by any unauthorised individuals.
  3. I give my consent to be interviewed by the consulting healthcare provider. I also understand that other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained.
  4. For Medical I understand that a limited examination may take place during the video conference and that I have the right to ask my healthcare provider to discontinue the conference at any time. I understand that some parts of the exam may be conducted by individuals at my location at the direction of the consulting healthcare provider.
  5. I agree that certain situations including emergencies and crises are inappropriate for tele-health services. If I am in crisis or in an emergency, I should immediately call or go to the nearest hospital or crisis facility.
  6. I hereby release Texas Medical Concierge, its personnel and any other person participating in my care from any and all liability which may arise from the taking and authorized use of my medical reports shared with them.
  7. The Medical Service Providers are independent entities / professionals in private practice and are neither employees nor agents of the Company and/or its parents, subsidiaries or affiliates. The Company does not recommend or suggest any particular Medical Service Provider or promote any particular Medical Service Provider’s name or practice. Further, the Company does not make any representations or warranties with respect to Medical Service Providers or the quality of the healthcare services they may provide. The Company shall not be responsible for any breach of service or service deficiency by any Medical Service Providers.
  8. Any advice provided by any Medical Service Provider or the virtual health service shall depend solely on the completeness and accuracy of the information provided by me. NeitherCompany nor any Medical Service Provider shall be responsible for any damage, whether physical, emotional, psychological or financial, caused to me due to any improper/unintended use of the Services, any coupon issued to me or any of the benefits available there under, which includes but is not limited to the misinterpretation of the advice given by any Medical Service Provider or virtual health service to me.
  9. The Service offered by Company and Medical Service Provider are provided on “As Is” and “As Available” basis and  may be subject to certain limitations Consequently in no event shall Company and/or any Medical Service Provider be liable to me or any third party for any indirect, consequential, exemplary, incidental, special, or punitive damages, including lost business/revenue/profit/goodwill or damages arising from my use or unavailability of the Services and/or any other the services offered to me by Company in any manner whether or not Company has been warned of the possibility of such damages or could have reasonably foreseen such damages. I shall not be entitled to specific performance of any of the Terms. The foregoing limitation of liability shall apply to the fullest extent permitted by law in the applicable jurisdiction and, regardless of the form of the action, will at all times be limited to the aggregate of amount received from me by Company for the Services in the 12 months preceding the cause of action. I specifically agree and understand that neither Company nor any Medical Service Provider is liable to me for any content or illegal conduct of any third party and that I alone accept such risk of harm.
  10. The views and suggestions expressed by Medical Service Providers in the course of providing the Medical Services shall in no manner be construed as an endorsement by Company. Company shall not be responsible in any manner whatsoever for any act, omission, treatment, diagnosis, advice, view, suggestion or opinion, whether medical or non-medical, professional or non-professional of any Medical Service Provider for any reason whatsoever.
  11. I have read this document and understand the risk and benefits of the telemedicine services and have had my questions regarding the services explained and I hereby consent to participate in a tele-health visit under the conditions described in this document.