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Informed Consent and Authorization

The following Statement of Patient Responsibility; Informed Consent and Authorization sets forth the terms under which Patient Health Services, LLC (“Patient Health Services”) is supplying you access to telephonic or electronic consultation services with a US-licensed Physician and other practitioners and your agreement to accept responsibility for your decision to seek these services thru Patient Health Services.

In order to determine your compliance with these Terms, we reserve the right, but not the obligation, to monitor your access to and the use of the site and the Services. Patient Health Services may, in its sole discretion, refuse to provide access to the site or services due to actual or potential misuse of the site, these Services, or for noncompliance with these Terms.

To fill any service requests, you must verify that you have read and understand these conditions, including the Statement of Patient Responsibility.

Statement of Patient Responsibility

In submitting my health information (symptoms, conditions, comments, answers to questions, and fully-completed Health Information Form) in connection with my request for services, the following statements are true:

I am an adult (at least 21 years of age).

I am competent to use the services offered by Patient Health Services, and I fully understand the material contained on this website.

I voluntarily choose to seek a physician consultation through Patient Health Services.

I recognize that the consulting physician reviewing my Health Information may or may not prescribe treatment based on my responses.

I am aware that my failure to provide truthful, accurate and complete information to the consulting physician and any other providers could result in an inappropriate treatment decision that could be harmful to me or not be safe and effective. Therefore, I have responded to each question on the Health Information Form truthfully and accurately and have fully and completely disclosed any and all information concerning my health and medical history that could be relevant to my current condition and need for treatment and/or medication.

I have been seen by a physician and have had a physical examination and/or medical history evaluation within one year of requesting services from Patient Health Services. I agree to undergo a physical examination every year to ensure that my request for treatment is appropriate, and to inform my personal physician about the products ordered or purchased, as applicable, thru Patient Health Services.

I will contact my physician if I have questions, difficulties or complications with recommended treatment(s).

I will make the Consulting Physician aware of any changes to my medical condition in the event I return to the site seeking services or products of any kind whatsoever.

I understand that Patient Health Services receives an electronic transmission of my request for a consultation and the reason for said consultation; directs my completed Health Information to a consulting physician for his/her review and response in accordance with the consulting physician’s professional judgment as to my request.

I understand that I am able to contact the Consulting Physician who reviews my Health Information Form through the Patient Health Services customer service number posted on the web site.

I understand that I will be given the opportunity to the consulting physician any and all questions about any tests, procedures or medication(s) that may have been prescribed for me.

I understand that the Consulting Physician is an independent, U.S. licensed practitioner; is not an employee or principal of Patient Health Services and is not my primary care physician.

I understand that there are risks as well as benefits in having tests performed or taking any medication.

If paying by credit or debit card, I am the owner of that credit or debit card or I am permitted by law to use such credit card.

Patient Agreement and Acknowledgement:

As a customer or potential customer of the services provided by or through this website, I hereby understand, accept, and agree to the following:

In order to determine your compliance with these Terms, we reserve the right, but not the obligation, to monitor your access to and the use of the site and the Services. Patient Health Services may, in its sole discretion, refuse to provide access to the site or services due to actual or potential misuse of the site, these Services, or for noncompliance with these Terms.

I am voluntarily providing my health and medical information and completing a Health Information Form for the purposes of obtaining services through Patient Health Services.

I realize that the consulting physician will not conduct an in-person physical examination and will rely on the truthfulness and accuracy of the information I am providing on my Health Information Form, supplemented by answers to follow-up questions and/or a telephone consultation.

I am using this technology platform because I am seeking access to medical advice and treatment from a qualified physician and/or other clinician.

I understand that a physician who is currently licensed in the United States will review my Health Information. Therefore, I agree that all online consultations, diagnoses, and treatments will be deemed to have occurred in the state where the consulting physician is licensed to practice medicine.

I am under the care of a personal physician and I do not consider the consulting physician to be my personal primary care physician.

I acknowledge that Patient Health Services does not practice medicine and is not a healthcare services provider. I further acknowledge that Patient Health Services cannot and does not direct, control or influence the medical opinions or decisions made by the consulting physician or other assigned clinician with respect to my care.

I agree that any dispute arising out of or related to the provision of services by Patient Health Services, by the consulting physician or other clinician, or by their affiliates, employees, partners and agents, will be subject to mandatory mediation. Should mediation fail to resolve the dispute issue(s), said dispute shall be subject to final and binding arbitration and that all parties will agree to be bound by the arbitration, which will be enforceable in a court and that the parties waive any rights to bring suit in favor of agreeing to binding arbitration.

Any mediation, arbitration, administrative proceedings, or other proceedings shall be held in Montgomery County, Pennsylvania, unless the parties agree otherwise, and shall be governed by the substantive law of the Commonwealth of Pennsylvania without regard to conflicts of law.

I accept all risks, known and unknown, involved in, arising from or related to taking the medication, products or treatment. Subject to and without waiving any rights that may be conferred upon me under state or federal law, I will not seek indemnification and/or damages whatsoever of any kind from Patient Health Services for negligent, reckless or intentional acts or omissions, and I hereby hold harmless Patient Health Services from and against any and all liability relating to or arising out of my request for or receipt of medications from Patient Health Services.

I hereby release Patient Health Services and the consulting physician and other clinician from any and all claims that the physician acted below the requisite standard of care on the basis that the physician did not personally examine me.

I hereby acknowledge that all information and service provided by or through this web site are provided “as is” without warranty of any kind, expressed or implied.

If any provision of this agreement is held to be illegal, void or unenforceable, then this agreement may be modified or amended only to the extent necessary to enable the remaining provisions to be of force and effect to the maximum degree.

Patient Authorization for Release of Individually Identifiable Health Information

In connection with providing certain individually identifiable health information to Patient Health Services, I authorize the following:

I hereby authorize Patient Health Services to use and disclose any of my health information, including all individually identifiable health information contained in the Health Information Form for the purpose of treatment, payment and health care operations. This authorization additionally includes, but is not limited to, any health information relating to HIV and other sexually transmitted diseases, mental health or disease, drug or alcohol treatments.

Patient Health Services’s privacy notice, provides more detailed information about our privacy policies, and you are encouraged to review it before agreeing to this authorization.

I declare under penalty of perjury that the foregoing is true and correct. My agreement to this statement constitutes my signature.