Consent to Receive Care Through Telehealth Technologies

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services also include remote monitoring, tele-pharmacy, prescription refills, appointment scheduling, regional health information sharing, and non-clinical services such as education programs, administration, and public health.

Doko MD (Doko Medical Inc.) providers may include primary care practitioners, specialists, and subspecialists. Information used during telehealth may include patient medical records, medical images, live two-way audio and video, interactive audio, and output data from medical devices and sound and video files.

Electronic systems used for telehealth incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and include measures to safeguard data integrity against intentional or unintentional corruption.

Primary responsibility for your medical care should remain with your local primary care doctor, if you have one. Your primary care doctor should also maintain responsibility for your medical record.

Expected Benefits

• Improved access to medical care by enabling you to remain at your local healthcare site, including home, while the provider consults and obtains test results from other locations.
• More efficient medical evaluation and management.
• Access to specialist expertise.

Possible Risks

• Delays in medical evaluation and treatment could occur due to deficiencies or failures in equipment and technologies.
• In rare situations, the provider may determine that transmitted information is of inadequate quality, requiring a rescheduled telehealth consult or a face-to-face meeting with your local primary care doctor.
• In very rare situations, security protocols could fail, causing a breach of privacy of personal medical information.
• In rare situations, lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgment errors.

Patient Consent

• I consent to receiving Doko MD services via telehealth technologies. I understand that Doko MD and its consulting providers offer telehealth services, but those services do not replace the relationship between me and my primary care doctor.
• I understand it is up to the Doko MD provider to determine whether my needs are appropriate for a telehealth encounter.
• I have been given an opportunity to select a consulting provider from Doko MD prior to the consult, including review of the provider's credentials.
• I understand that federal and state law requires healthcare providers to protect the privacy and security of health information, and I understand that Doko MD will take steps to help ensure that my health information is not seen by unauthorized persons.
• I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including outside my state.
• I understand there is a risk of technical failures during the telehealth encounter beyond Doko MD's control, and I agree to hold harmless Doko MD for delays in evaluation or information lost due to those technical failures.
• I understand that I have the right to withhold or withdraw my consent to telehealth at any time without affecting my right to future care or treatment.
• I understand that I may suspend or terminate access to the service at any time for any reason or for no reason.
• I understand the alternatives to telehealth consultation, including in-person services, are available to me, and that some services involving physical tests may be conducted by individuals at my location or at a testing facility at the direction of the Doko MD consulting healthcare provider.
• I understand that video images and audio recordings of me may be captured and stored electronically and may later be viewed and used for evaluation, education, and training, which may include non-physician personnel and students. I consent to that use in connection with telehealth consultation and related evaluation, education, and training.
• I understand that anticipated benefits may result from telehealth in my care, but that no specific results can be guaranteed or assured.
• I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes and that persons may be present during the consultation to operate telehealth technologies. I understand I will be informed of their presence and may request that sensitive details be omitted, that non-medical personnel leave, or that the consultation be terminated.
• I understand that I will not be prescribed Drug Enforcement Agency controlled substances and that there is no guarantee that I will receive any prescription.
• I understand that if I participate in a consultation, I have the right to request a copy of my medical records, which will be provided at a reasonable cost of preparation, shipping, and delivery.

Website and Service Limitations

I understand that in the event of any problem with the website or related services, my sole remedy is to stop using the website or terminate access to the service. Under no circumstances will Doko MD or any subsidiary or affiliate be liable for losses or damages arising directly or indirectly from use of, inability to use, or results of use of the website, linked websites, or materials and information available through them.

I agree that I will not hold Doko MD, its subsidiaries, or affiliates liable for punitive, exemplary, consequential, incidental, indirect, or special damages, including personal injury, lost profits, business interruption, or loss of data, arising from or in connection with use of the website, whether under a theory of breach of contract, negligence, strict liability, malpractice, or otherwise, even if advised of the possibility of such damages.

I understand that Doko MD makes no representation that materials on this website are appropriate or available for use outside the United States. If I access these services from outside the United States, I do so at my own risk and am responsible for compliance with applicable laws and regulations.

Follow-Up Care and Technical Failures

If you need follow-up care, assistance in the event of an adverse reaction to treatment, or help in the event of an inability to communicate due to technological or equipment failure, contact Doko MD at 1-888-910-DOKO (3656) or support@doko.md, and notify your primary care doctor or emergency medical services as appropriate.

Additional Texas Consent

The following disclosures apply to Texas users accessing the Doko MD website for participation in a telehealth consultation.

Final Acknowledgment

I have read this document carefully and understand the risks and benefits of telehealth consultation. I have had my questions regarding the procedure explained, and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.

By signing into the Doko MD app, portal, or related systems, I state that I have read, understood, and agree to the terms of this document.