Telehealth Consent Form

Thank you for choosing VisionaireMD ("Skinny Theory") and Beluga Health, P.A. (“Beluga”)! You are viewing this form because you have elected to engage in asynchronous telemedicine visits with a Beluga healthcare practitioner via Skinny Theory. Your practitioner is a board-certified physician licensed in your state.

By clicking “I Agree,” I ACKNOWLEDGE I HAVE READ AND UNDERSTAND THE TERMS PRESENTED BELOW, AND UNDERSTAND THE RISKS AND BENEFITS OF ASYNCHRONOUS TELEMEDICINE, AND BY ACCEPTING THESE TERMS OF USE I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN ASYNCHRONOUS TELEMEDICINE UNDER THESE TERMS.

What is Telemedicine?

Telemedicine is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare practitioner. Beluga allows you to receive treatment from a healthcare practitioner without having to travel to another location or schedule a separate appointment and helps you avoid long wait times that you might otherwise experience at an in-person visit.

What is Asynchronous Telemedicine?

Asynchronous telemedicine is one way to deliver telemedicine. Asynchronous communication is often referred to as “store-and-forward” communication, where participants submit and collect data at different times. An example of asynchronous communication is a telemedicine encounter with a healthcare practitioner that involves sending photos, video, or other communications via email or text message. “Asynchronous” means “not occurring at the same time” and is different from “synchronous” telemedicine, which generally includes visits conducted in real-time between patients and healthcare practitioners through audio or video means (e.g., live phone calls or video-conferencing). Healthcare practitioners may use asynchronous telemedicine to aid in diagnoses and medical consultations when live communication or face-to-face contact is not possible or necessary.

Beluga’s platform (“Platform”), in particular, allows for the following asynchronous telemedicine services: 1) text-based healthcare practitioner-patient interactions through short message service (“SMS”) and multimedia messaging service (“MMS”) communications; and 2) secure information collection through asynchronous store-and-forward patient questionnaires.

What are the Possible Risks to Using Asynchronous Telemedicine?

As with any medical treatment, there are potential risks associated with the use of asynchronous telemedicine. Beluga believes that the likelihood of these risks materializing is very low.

These risks may include, without limitation, the following:

• Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your healthcare practitioner should these interruptions occur.

• Security protocols could fail, causing a breach of privacy of personal medical information.

• Because Beluga does not have access to your complete medical records, if you do not disclose to your healthcare practitioner a full list of your medical history including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions or allergic reactions, or other negative outcomes may occur.

• Asynchronous telemedicine services are NOT emergency services and your Personal Data (as defined in the Beluga Privacy Policy) WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.

THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE HEALTHCARE PRACTITIONER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTHCARE PRACTITIONER WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR THE CARE PROVIDED THROUGH AN ASYNCHRONOUS TELEMEDICINE ENCOUNTER VIA THE PLATFORM.

Your Rights and Acknowledgements:

• You have the same privacy rights via asynchronous telemedicine that you would have during an in-person visit. Dissemination of any identifiable images or information from the asynchronous telemedicine visit to researchers or other entities will not occur without your written consent. For more information about how we protect your privacy, please read the Beluga Privacy Policy here
• Asynchronous telemedicine may involve electronic communication of your personal medical information to healthcare practitioners who may be located in other areas, including out of state.
• You understand that you may expect the anticipated benefits from the use of asynchronous telemedicine, but that no results can be guaranteed or assured.
• You understand that all information submitted to Beluga via text message and entered by your healthcare practitioner in the Beluga Platform will be part of your medical record and available to you by emailing admin@belugahealth.com. This information will have the same restrictions on dissemination without your consent.
• You understand that your healthcare practitioner’s initial text message to you will include his/her name and credentials, and this will be recorded in the Beluga Platform as part of your medical record.
• You understand you may withdraw your consent and delete your patient profile at any time by emailing admin@belugahealth.com.‍
• You understand that your healthcare information may be shared with other individuals in accordance with the Beluga Privacy Policy and regulations or laws in state or territory in which you are located.
• You further understand that your healthcare information may be shared in the following circumstances:
  • When a valid court order is issued for medical records.
  • Reporting suspected abuse, neglect, or domestic violence.
  • Preventing or reducing a serious threat to anyone's health or safety

Call/Email/Text Messaging Consent: You expressly consent to allow Beluga or its healthcare practitioners to call, email, or text you (via SMS and/or MMS) with or regarding Personal Data (as defined in the Beluga Privacy Policy), appointments, or similar matters related to your telemedicine encounters using the contact information you have provided. Any calls or texts to you may be placed using an auto-dialer or a pre-recorded or artificial voice, even if your number is on a do-not-call list. Your phone carrier’s normal rates may apply. This is consent, not a condition of purchase. You may revoke this consent at any time by emailing us at admin@belugahealth.com.

This Asynchronous Telemedicine Informed Consent is valid during your entire treatment with Beluga.