This medical evaluation is not intended to be construed as a general or complete medical examination. It is for purposes of medical/legal assessment only and focuses on establishing qualifications for the approval of specific medical spa center treatments. Today’s clinical evaluation with Spakinect is not intended to diagnose or treat any particular medical disorders, nor is the relationship established with SpaKinect Corp. designed to replace or substitute for ongoing medical care from your health care providers. The medical evaluation conducted today with Spakinect will not guarantee the patient, issuance of a “Provider Approval.”
Some medical disorders may require additional medical evaluations, diagnostic testing, and/or medical records as deemed appropriate by the health care professionals at Spakinect to decide if my specified diagnosed medical disorders justify my being issued by Spakinect a “Provider Approval”. As with any treatment, there is a potential for adverse effects, and care should be taken not to place yourself or other individuals at risk of harm. Should any medical problems develop, prompt medical evaluation and treatment from your health care provider or an emergency department should immediately be sought. Should a “Provider Approval” be approved and issued to me by Spakinect and its health care providers to permit me to receive treatment, it is expressly understood that I the undersigned, his/her heirs, assigns or anyone acting on his/her behalf, agree that Spakinect its principles, agents, associates, and employees are free from all liability, harm or injury to myself because of my receiving treatment.
By checking the box; you agree to the following.
My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation. I understand that this consultation will not be the same as a direct patient/health care provider visit since I will not be in the same room as my health care provider.
I understand there are potential risks to this technology, including interruptions, and technical difficulties. I understand that my health care provider(s) or myself can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
I understand that others may also be present during the consultation other than my health care provider and consulting health care provider to operate the video equipment. The above-mentioned people will all maintain the confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.
I understand that my evaluation may be recorded for quality assurance and for internal use ONLY. All video/digital recordings are carried out according to guidelines issued by the medical board of each state in which Spakinect operates. Spakinect follows all HIPAA regulations regarding the taking and storing of video consultations.
In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the videoconference connection.
I have read this document carefully and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained, and I hereby consent to participate in a telemedicine visit under the terms described herein. I, the undersigned patient of Spakinect, under penalty of perjury, hereby declare that all the information I am providing today to Spakinect, be accurate and correct.
