Effective Date: April 5, 2020



As the patient (or as the legal guardian or healthcare conservator of the patient) and user for this telemedicine consultation, I voluntarily give my permission to the health care providers of “Dr. Ansay AU-Schein GmbH” (referred to as "DrNote", "we", "us", or "our") and such assistants and other health care providers as they may deem necessary to provide medical services to me. I understand by signing this form, I am authorizing them to treat me for as long as I seek care from DrNote, or until I withdraw my consent in writing.
 

By filling out this intake form I will help my doctor assess the suitability of using telemedicine services by verifying my full name, my current location, my readiness to proceed. By signing this consent, I understand and agree to the following: 
 

  1. All DrNote doctors are licensed in different US states, and this service is for residents of those US states only, and I hereby warrant that I reside in the according state. My doctor may not be able to assist me when I am located in any other state or country.
     

  2. Care by DrNote or a DrNote consultation does not replace the need for ongoing care by a primary care doctor; after a consultation for an acute complaint I understand that DrNote always recommends talking to my primary care doctor within a week at the latest to discuss the symptoms.
     

  3. I know that DrNote is only able to take care of the conditions mentioned on the website. I acknowledge that this service is not intended to treat dangerous life and limb-threatening emergencies. If I require emergency care, I am aware that telemedicine is not the right type of care, and I should call 911 or proceed to the nearest hospital emergency room for help.
     

  4. I acknowledge that DrNote doesn´t offer any service to receive prescriptions.
     

  5. I submit to the exclusive jurisdiction of the state´s superior courts in which my doctor resides and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services provided by my doctor and my doctor’s staff will be brought solely and exclusively in the state in which my doctor resides state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of the state in which my doctor resides. 
     

  6. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured. 
     

  7. If my doctor believes at any time that another form of service (for example, a traditional in-person consultation) would be appropriate in the situation, my doctor may discontinue the telemedicine consultation and recommend an in-person consultation. In that case I may request to get a refund for the consultation. 
     

  8. I am comfortable with using electronic communications technology to communicate with my doctor and understand there are limitations to the technology which may require an in-person consultation.

    If I have a video-consultation, I agree to have the necessary smartphone, WhatsApp and internet access for my telemedicine communications. I also agree to try my best to arrange for a location with sufficient lighting and privacy and is free from distractions and intrusions during my telemedicine communications. If there is a technical problem with the video, I agree that the DrNote doctor may complete the consultation through a phone call.

     

  9. The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted electronically by my doctor to me will be encrypted during transmission and will be stored only by my doctor or a service provider selected by my doctor. I understand the dissemination of any personally-identifiable images or information from the telemedicine communication to researchers or other healthcare providers will not occur except as required by federal or state law. 
     

  10. I understand my risks of a privacy breach increase substantially when I enter information on a public access computer, use a computer that is on a shared network, or use my work computer for personal communications.
     

  11. I acknowledge that DrNote providers may email me information relating to my consultation or follow up with me using the email address I provided. I am aware that information sent by email may not always be fully secure. If I do not want to receive any emails regarding my visit, I will let my doctor know during the consultation. I have the right to access my medical information and obtain copies of my medical records in accordance with state law.
     

I read and understand the information provided in this document. I discussed any questions I may have had with DrNote beforehand and all of my questions were answered to my satisfaction.

By clicking “I agree,” I acknowledge and accept the Consent to Treat as stated above.

Telemedicine Consent

Any questions?

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