Acknowledgment And Consent For Telehealth Services

The Pill Club Medical Group Services

The Pill Club Medical Group (“The Pill Club”) offers contraceptive services through telehealth technologies. Telehealth is a mode of delivering health care services via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of health care, while patients and their health care providers are in different sites. Telehealth involves the use of technology to optimize avenues and accessibility for contraception between our health care providers and patients.

While telehealth may improve access to healthcare and lead to more efficient diagnosis, treatment, and care management, there are potential risks associated with telehealth, as there are with any medical treatment or procedure. The potential risks associated with telehealth include, but are not limited to: insufficient transmission of information that does not allow for appropriate decision-making and diagnosis by the health care provider; delays in diagnosis, consultation, and/or communication due to deficiencies.

Use or Disclosure of Health Information

The Pill Club may use or release your health information to other healthcare providers and their staff for treatment purposes, to third party payers, and other third parties as necessary for The Pill Club Medical Group to obtain payment for services rendered for healthcare operations (e.g.: administration, patient care support, quality assurance, pharmacy, etc.). The Pill Club reserves the right to provide treatment based on the accuracy provided by the patient regarding health history, health conditions, current medications, etc.

I authorize treatment for contraceptive services from The Pill Club Medical Group and understand the following:

Patient Responsibility & Accountability

I understand I am answering the questionnaire in all honesty and accuracy.
I understand that if I choose to withhold or provide inaccurate information reflective of my health history to receive contraceptive services--this may cause serious side effects that may be detrimental to my health and may cause death.
If the stated above occurs, I understand The Pill Club Medical Group will not be legally responsible for patient, as many efforts are provided emphasizing importance of reading consent.
I understand The Pill Club Medical Group has the right to refuse to take responsibility for my care if the healthcare provider finds I am not an optimal candidate for telehealth services as safety is their number one priority
I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to treatment or care in the future.
I understand that it is my duty to inform my health care provider of my medical history and details regarding my condition in order for The Pill Club’s Medical Group’s healthcare providers to provide the best care possible.
I understand my participation in telehealth services at The Pill Club is completely voluntary and my decision to proceed with the services provided by The Pill Club is entirely within my discretion at all times.
I understand that I am requesting birth control for pregnancy prevention and other indications (e.g.: acne, management of dysmenorrhea and menorrhagia, regulation of periods with no serious underlying conditions, etc.)
I understand The Pill Club does not manage any new and/or pre-existing health diagnoses.

Medical Interaction

I am at least 12 years of age.
I have seen a doctor in the last 6-12 months and understand the importance of seeing a doctor regularly as The Pill Club Medical Group services do not substitute an in-person office visit.
I am a current resident in either my sign-up state or prescribing address provided upon sign-up.
I understand to the best of my knowledge that I am not currently pregnant which supports my decision to request telehealth services at The Pill Club for pregnancy contraception.
I understand that the details of my telehealth interaction may include oral, visual, and electronic communications between me and my health care provider
I understand the details of communication as a patient with The Pill Club Medical Group will become part of my medical records.
I understand there may be time delays from which I sign up as a telehealth patient to when my healthcare provider reviews my requests for contraceptive treatment(s).
I understand that it is my duty to inform my health care provider of my medical history and details regarding my condition in order for The Pill Club’s Medical Group’s healthcare providers to provide the best care possible.
I understand that I can contact The Pill Club if I should have any non-urgent issues, questions, or concerns and a healthcare professional may not respond until the next business day or operating hours.
I understand by making request for service (by completing the health history questionnaire or making payment) that this action does not establish patient/provider relationship or duty of care.
I understand that once provider has reviewed the provided information and determined the candidate is an appropriate patient for telehealth services does the provider assume responsibility for care.

Telehealth Limitations

I understand that I may expect certain anticipated benefits of the use of telehealth by my healthcare providers, but that no outcomes or results are guaranteed.
I understand that telehealth-based services may not be as complete or appropriate as face-to-face interactions under certain circumstances, and my health care provider may refer me to another health care provider for
I understand that nothing within this consent precludes me from seeking or receiving in-person care if I choose, even after consenting to receive services via telehealth.
I understand The Pill Club Medical Group provides limited scope of services primarily for contraceptive proposes with patient education
I understand that The Pill Club Medical Group Services do not substitute
any in-person medical visits to support healthcare promotion and maintenance, routine screenings, etc.
I understand that in an event of an emergency, I will call 911 and/or go to the nearest emergency department.

Adverse Effects & Events

I understand I am putting my health and life in harm if I provide information that is incomplete and untrue, while taking prescribed contraceptive method.
I understand that the accuracy in the information provided for the following: ○ Age ○ Gender ○ Blood pressure ○ Health history ○ Pregnancy status Is vitally essential in The Pill Club Medical Group’s determination if I am an optimal candidate for services provided
I acknowledge that although birth control is safe for most women, some potential side effects and adverse reactions including, but not limited to: migraines, blood clots (e.g.: pulmonary embolus, deep vein thrombosis (DVT), etc. stroke, irregular bleeding, etc.)
I further acknowledge serious side effects of birth control provided by The Pill Club Medical Group (ACHESS acronym); have been provided and h this consent. (A)bdominal pain--severe, upper right side; (C)hest or arm pain--severe, shortness of breath; (H)eadaches so severe, they are not relieved with over-the-counter oral analgesics (Tylenol, Aspirin, ibuprofen); (E)ye problems, blurry vision; (S)welling or redness, severe leg pain; (S)uicidal ideations or thoughts to harm oneself or others.
I understand that if I experience any of the following serious side effects of birth control listed above, it is my responsibility to seek immediate medical attention at a nearest emergency room for further evaluation.
I understand that although benefits of contraception outweigh risks, estrogen-containing contraceptives such as the: pill, or ring, may have higher risks of side effects than a progestin-only pill (POP).

Pharmacy Options

I understand that I may take a prescription I receive from The Pill Club Medical to any pharmacy of my choice. I am under no obligation to fill the prescription at the Pill Club Pharmacy.
I understand that with my permission and personal request, results of my telehealth encounter will be made available to my primary care physician, OB-GYN, etc.

Financial Responsibility

I understand I am responsible for paying services at the time contraceptive services are rendered, unless The Pill Club Medical Group has an agreement with your health plan insurer and the services are under your plan
If The Pill Club Medical Group has an agreement with your health plan or insurer, the patient is responsible for paying the co-payment and/or deductible amounts at the time of service.

Acknowledgement Of Content Provided

I understand the importance of reading and acknowledging the information provided in this consent
I understand the importance of reading all material thoroughly that is provided via SMS text from healthcare providers at The Pill Club Medical Group and reading material in all shipment packages pertaining my birth control
I understand that if I should have any general questions or concerns regarding my contraceptive methods, I can let The Pill Club know and a member of the medical team will respond during operating hours (this does not pertain to urgent emergencies)

I have read and understand the information provided above regarding telehealth, including the potential risks. I have had the opportunity to discuss the use of telehealth with The Pill Club health care provider and to ask questions regarding the use of telehealth, and all of my questions have been answered to my satisfaction.

By clicking “Start”, I am confirming that I understand the above disclosures, consent to the treatment, and have received The Pill Club’s Notice of Privacy Practices. I hereby provide my consent to engage in telehealth with The Pill Club’s health care providers and authorize The Pill Club’s health care providers to use telehealth in the course of my diagnosis and treatment.