Telemedicine Concent

Informed Consent for Telemedicine Services

Introduction

Telemedicine involves the use of electronic communications to enable health care providers to diagnose and treat patients at different locations and to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

Patient medical records
Medical images
Live two-way audio and video
Output data from medical devices and sound and video files

Electronic systems used 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.

Expected Benefits:

Improved access to medical care by enabling a patient to remain in his/her home or office while interacting with healthcare practitioners at distant/other sites.
More efficient medical evaluation and management.
Obtaining expertise of a distant specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks
include, but may not be limited to:

In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;

I understand the following:

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.
I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.
I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
By scheduling a telemedicine appointment and accessing the Health Care Services, I acknowledge and agree to this Telemedicine Consent and a record of such acknowledgement will be retained in the medical record of the medical provider and professional entity providing such Health Care Services.

Illuminate Your Life with Color

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Illuminate Your Life with Color

Revive vibrancy in your life with our therapy. Book now to rediscover life’s brilliance.

Colorful Patient Testimonials

Real stories, real impact: discover their journey to wellness

Colin McCarthy

Clean, professional, and punctual

My doctor prescribed Ketamine treatments to me for my depression. After looking around a bit, treatments at this clinic seemed quite reasonably priced. The facility is top-notch. Clean, professional, and punctual.

View the full review on Google

Alexander Grim

They truly make you feel comfortable

Employees are incredibly nice and supportive. While the treatment can be little scary, they truly make you feel comfortable and safe while you are there.

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Bre W.

Wonderful clinic

This clinic is wonderful. From the receptionists to the medical assistants to Dr. Shinde! I’ve been getting ketamine administered here for 3 weeks and it’s definitely provided me such a large relief with my depression

View the full review on Google

Jessie

Incredible experience!

Balance Ketamine Clinic at AAYU has been an incredible experience! The environment is clean and atmospheric. They have a modern/minimalism feel that you don't see in most clinics. I felt safe in the room where the ketamine is given.

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Matt

I feel like myself again

I must say I was skeptical if this would work. I didn't feel very different immediately after my first infusion but then after the 2nd and 3rd -something began to life. Now after 6 infusions -I feel like myself again!

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FAQs

Find answers, gain clarity, and embark on your journey with confidence

What is IV ketamine therapy?

Ketamine is an anesthetic medication that blocks the NMDA receptor that has also been used as a recreational drug due to its dissociative properties. It is on the World Health Organization’s List of Essential Medicines because of its safety and efficacy for anesthesia. More recently, ketamine has been discovered as a safe and effective treatment for depression, and randomized controlled trials have shown rapid improvement in mood as well as reduction in suicidality compared to people who receive a placebo or another drug.

Is ketamine right for me?

Adults age 18 and over who suffer from severe depression and have not had success with traditional treatments for depression are eligible for ketamine treatment. Our comprehensive evaluation will include a medical history and basic lab results to ensure ketamine therapy is safe for you.

How does IV ketamine therapy work?

Several randomized controlled trials demonstrate that ketamine has made a significant improvement in depressive symptoms and suicidality over the course of the first 2 weeks. In fact, if ketamine does not work for you after 2 sessions, the data suggest it is unlikely to work at all. Several studies have looked at how long the effects of Ketamine last. This graph shows just one such study’s results.

Are there any risks associated with ketamine therapy?

For depression, the doses of ketamine used are much lower than the dose for anesthesia, making it relatively safe. That said, ketamine does carry the risk of changing your blood pressure and heart rate, which we will monitor throughout the ketamine infusion therapy. Longer term risks include urinary symptoms, cognitive impairment (with prolonged use), and substance use disorders. We will monitor for these symptoms throughout the treatment.

When considering ketamine treatment, patients want to know how much ketamine depression treatments cost. Ketamine therapy can be very effective in relieving the symptoms of treatment-resistant depression.

Telemedicine Concent

Introduction

Expected Benefits:

Possible Risks:

I understand the following:

Illuminate Your Life with Color

Illuminate Your Life with Color

Colorful Patient Testimonials

Colin McCarthy

Alexander Grim

Bre W.

Jessie

Matt

FAQs

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