Informed Consent
Since Rev(IV)al Hydration provides primarily mobile rehydration therapy services, Rev(IV)al Hydration may use “telemedicine” to facilitate electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, nurse 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 their office, home, or any other remote location while a physician obtains test results as necessary and consults from healthcare practitioners at distant/other sites.
• More efficient medical evaluation and management.
• Obtaining the expertise of a remote specialist.
Potential Risks
As with any medical procedure, there are potential risks associated with the use of electronic communications to facilitate the provision of medical services via 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;
. May experience discomfort, bruising, and pain in the injection site.
. May cause inflammation of the vein used for injection, phlebitis.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
.Severe allergic reaction, anaphylaxis, cardiac arrest, and death.
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions allergic reaction or other judgment errors;
Please initial after reading this page:
Informed Consent
BY SIGNING THIS FORM, I ATTEST TO AND UNDERSTAND THE FOLLOWING:
1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine and the use of electronic communications therein, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
2. 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.
3. I understand that I have the right to inspect all information obtained and recorded in the course of telemedicine interaction, and may receive copies of this information for a reasonable fee.
4. 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. Rev(IV)al Hydration and or its service providers has explained the alternatives to my satisfaction.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that it is my duty to inform Revival Hydration and its providers of electronic interactions regarding my care that I may have with other healthcare providers.
7. 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.
8. I attest that I am located in the state of California and will be present in the state of California during all telehealth encounters with Rev(IV)al Hydration.
9. I understand that I can request removal or deletion of any potentially personally identifiable information electronically stored by Rev(IV)al Hydration.
10. I understand that, if I have any reason to believe that any of my personally identifiable or personal medical information may have been compromised or breach in any way, I can reach out to Rev(IV)al Hydration at [ADD EMAIL] to report such comprises so that Rev(IV)al Hydration can have an opportunity to investigate and assist in the protection of such information.
Patient's Consent
I have read and understood the information provided above regarding telemedicine and electronic communication of my personal medical information, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.
I hereby authorize Rev(IV)al Hydration the use for the course of my diagnosis and treatment.