NEW  PATIENTS

 Telemedicine Informed Consent

 

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.

 

1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.

2. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.

3. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties. a. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.

 

4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment. 

 

5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.

6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes. a. I understand that my insurance carrier will have access to my medical records for quality review/audit.

b. I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telemedicine visit.

c. I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.

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7. I understand that this document will become a part of my medical record.

 

By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).

 

We believe that services falling outside scope of services including diagnosis and treatment of the disease and correction of trauma or injury by a Physician or a Surgeon are not a Practice of Medicine. Thus Aesthetic services shall not be considered as a Practice of Medicine per se.

 

Clients agreeing to proceed with Aesthetic services release The Pout Medical Aesthetics Physicians, Aestheticians, Nurses, Injectors and it’s other personnel, agents, officers, contractors from HIPPAA liability.

 

By proceeding I agree with terms & conditions and provide my full consent for a teleconsultation.

 

Release Form

Release Form. All of the above information is true and accurate to the best of my knowledge. I take full responsibility for alerting MD /Physician and/or Cosmotologist/Esthetician to any physical or mental condition which would affect my service or results. I understand and acknowledge there are risks involved with aesthetic services. When injecting, bruises are unavoidable. So, I make sure I do not request such procedure before any event, modeling, photo shooting, etc where my look may affect my reputation or any material benefit. I have had the opportunity to ask questions regarding these risks and other possible complications. I understand any false or misleading information I have given may lead to undesired results and complications and hereby waive Dr. Feste, NP Carol Deutsch and The Pout Medical Aesthetics liability if such results or complications occur. I further understand my failure to follow post care instructions may also lead to undesired results, complications or effects and hereby waive Dr. Feste, NP Carol Deutsch and The Pout's liability if such results or complications occur. In consideration for The Pout Medical Aeshetics performing this procedure, I agree I will assume the risk and full responsibility for any and all injuries, losses, or damages, which might occur to me while I am undergoing this procedure or side effects I may experience after the procedure is performed. I understand that the MD Physician, Nurse and Esthetician in this Practice do not diagnose illness, disease, or any other physical or mental conditions. To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against Dr. Feste, NP Carol Deutsch and Cosmetic Injcetor Jennifer Wittkopp The Pout Medical Aesthetics its owners, officers, employees, or agents for negligence, injury, loss, death, costs or other injuries or damages to me as a result of this procedure. I agree this waiver and release shall bind the members of my family and any spouse or domestic partner, if I am alive, as well as my estate, family, heirs, administrators, personal representatives or assigns if I am deceased, and shall be deemed as a “Release, Waiver, Discharge and Covenant” not to sue Dr. Jospeh Fetste, NP Carol Deutsch, Jennifer Wittkopp & The Pout Medical Aeshetics LLC. I understand that photography and/or video is a necessary part of planning and evaluating cosmetic procedures and an instrument for disclosing to public portfolio “before and after”. I authorize the taking of photographs and/or video at the direction of my physician or physician delegate and under such conditions as may be approved by him/her. These photographs can be used whether solely for internal documentation purposes or both for internal and for publication on website and social profile, unless specifically requested not to publish them as a part of portfolio. Results of procedures vary and are not guaranteed for any procedure. Procedures are non-medical as are not related to diagnosing and treatment of diseases. I understand that not all procedures require Food and Drug Administration (FDA) approval, and so, those procedures which are considered as a part of Medical / Health Practice may have FDA approval or may not have it. As for example Botox was approved by the FDA for neck spasms, but has been used in a non-FDA approved manner by cosmetic surgeons for the past 15 years for wrinkles. The FDA finally approved the use of Botox for the treatment of glabellar wrinkles (wrinkles between the eyes) in 2002. Or, for example, Tattoo or Piercing or Aesthetic Implant procedures were never approved by FDA. As per MD Anil Shah: “Although FDA approval doesn’t guarantee safety or effectiveness, it is a successful regulatory body that can be referenced for unbiased information.” Please ask Practitioner if you have any questions, comments or concerns. You may read useful links about that here:
https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm047470.htm
https://www.fda.gov/AboutFDA/Transparency/Basics/ucm194879.htm
https://www.fda.gov/AboutFDA/Transparency/Basics/ucm553038.htm https://www.shahfacialplastics.com/articles/procedurefdaapproved
https://www.fda.gov/NewsEvents/ProductsApprovals/ucm106288.htm

INTELLECTUAL RIGHTS & PRIVACY STATEMENT

This Form is an intellectual property and copyright of The Pout Medical Aeshetics LLC and it’s respective shareholders. This Form can not be shared, distributed, copied, opened for public access without a written permission of the owner.

 

PRIVACY STATEMENT

The Form itself and the data accompanying this Form contain strictly confidential information that is legally privileged and protected by federal and state law.  This information is intended for use only by The Pout LLC.

 

 If you are in possession of this Form and it’s protected information, and are not the intended recipient, you are hereby notified that any improper disclosure, copying, or distribution of the contents of this information is strictly prohibited.  Please notify the owner of this information immediately and arrange for its return or destruction.

 

NOTICE

 

By proceeding, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.