PLEASE READ EACH SECTION CAREFULLY.  YOU MAY REQUEST A COPY OF THIS FORM FOR YOUR OWN RECORDS.

I, the undersigned, request and consent to an evaluation and treatment by OVME, its affiliated professional entities and its staff (collectively, “OVME”).  I wish to rely on OVME to exercise judgment for my best interest during the course of treatment, including any related procedures performed by OVME.  I will inform OVME or its staff who are treating me of any physical conditions, sensitive areas or adverse conditions that I may have had prior to, during, or after treatment and/or procedures.  I intend for this consent to cover the entire course of treatment and any related procedures.

I understand that any questions I may have regarding the treatment or treatment area, alternatives to the treatment, potential side-effects, and complications should be directed to the attending OVME staff member during my evaluation and course of treatment.  I acknowledge and agree that I have had the opportunity to ask questions of the attending OVME staff member and my questions have been answered to my satisfaction.

I understand that the practice of medicine and provision of medical aesthetics services is not an exact science. I further understand and accept that fees are paid for performance of services only, and not a guaranteed result.  I acknowledge by my signature below that although a good outcome is expected, and a reasonable effort has been made to establish realistic expectations, there cannot be any warranty, expressed or implied, as to the results that may be obtained.

Treatment Disclosure and Acknowledgement

The nature of the procedure and/or treatment described below has been explained to me, and I have separately consented to treatment by OVME. I understand that just as there may be benefits from the procedure, all procedures involve risk to some degree.

THE TREATMENT/PROCEDURE 

Telehealth and Pharmacy Services

OVME provides websites and/or applications through which you, may obtain an online visit with an independent, licensed health care professional in your area and as a result also may opt into mail order or online pharmacy services for medications prescribed to you as a result of your specific medical needs or diagnosis.

The services are known to constitute a form of telehealth, which involves the delivery of healthcare services using electronic communications between a health care provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education. “Telehealth” means the use of synchronous or asynchronous telecommunications technology by a telehealth provider to provide health care services, including, but not limited to, assessment, diagnosis, consultation, treatment, and monitoring of a patient; transfer of medical data; patient and professional health-related education; public health services; and health administration. The term does not include audio-only telephone calls, e-mail messages, or facsimile transmissions.

In addition, Telehealth services may include, but is not limited to:

• Electronic transmission of medical records, photo images, personal health information or other data between a patient and a provider.
• Interactions between a patient and a provider via audio, video and/or asynchronous data communications, such as secure messaging and email; and
• Use of data from remote monitoring devices, medical devices, and sound or video files.
• The websites, and information systems used in the services incorporate network and software security protocols to protect the privacy, security, and integrity of your health information.

Potential Benefits of Telehealth

• Telehealth may allow you to more easily, efficiently, and with less expense, access medical care.
• Medical care and treatment may be scheduled at a more convenient time for you.
• A telehealth provider may use telehealth to perform a patient evaluation and if you qualify Telehealth Provider is not required to conduct a physical examination before using telehealth to provide health care services to you.

Potential Limitations of Telehealth

• Information transmitted to your provider may not be sufficient to allow for appropriate medical decision making or your provider may not be able to provide medical treatment for your condition via telehealth, and you may be required to seek alternative care or a physical examination.
• The inability of your provider to conduct certain tests or assess vital signs in person may in some cases prevent the provider from diagnosing or treating you or identifying that you need urgent medical care, and you may need to have a physical examination.
• If there are technological failures and lapses in service, your medical care could be delayed.
• By the very nature of electronic submission, technology and means of use a breach of your identified health information due to the failure of data security protocols and/or safeguards.
• Due to the regulatory and legal requirements in your jurisdiction and the nature of the Services treatment options, especially pertaining to certain prescriptions, may be limited.

By signing this consent, you acknowledge your understanding and agreement to the following:

• I understand that I cannot obtain emergency care through the services.
• I understand, if emergency care is needed, I should call 9-1-1 and seek immediate medical treatment if I am experiencing a medical emergency.
• I give my informed consent to receive medical care and treatment by telehealth.
• I understand that the delivery of health care services via telehealth is an evolving field and that the use of telehealth in my medical care and treatment may include uses of technology not specifically described in this consent.
• I understand that a technical failure affecting the services may result in the loss of my information and/or interrupt my online visit. In addition to any disclaimers included at the OVME Terms of Service located at https://ovme.com/pages/terms-of-service, I agree to hold OVME harmless for any loss of information or delay in care resulting from a technical failure.
• I understand that while the use of telehealth may provide benefits to me, as with any medical care service no such benefits or results can be, or are, guaranteed.
• I understand that my condition may not be improved and/or cured, and in some cases, may get worse.
• I understand that I have a duty to answer questions about my health and medical history honestly and accurately, and to keep all my health care providers, including my provider, up to date on any changes in my health, symptoms, treatments, or medications.
• I understand that withholding or providing inaccurate information about my health and medical history to obtain treatment may result in harm to me, including, in some cases, death.
• I understand that I have access to all my health and wellness information pertaining to my telehealth consultation with my Provider in accordance with applicable laws and regulations applicable to my jurisdiction.
• I understand that my Provider may determine in his or her sole discretion that my condition is not suitable for treatment using telehealth, and that I may need to seek medical care and treatment in person or from an alternative source.
• I understand that the Services enable coordination and communication with a Provider and do not replace my relationship with any existing health care provider.
• I understand that my information, including my identified health information, will be collected, used, shared, and protected as described in OVME’s Privacy Policy which is available at www.ovme.com/pages/privacy-policy.
• I understand that if applicable, my provider, will share my telehealth record with my other health care providers only with my consent and at my request. I understand that I can have my telehealth record sent to my other health care providers by emailing my provider and providing my consent along with my health care provider’s name, address, and phone number.

PAYMENT OBLIGATION FOR PROCEDURE/TREATMENT

I understand that this is an elective procedure and/or treatment and that payment is my responsibility and is expected at the time of service. Payment is due in full at the time of service. I understand that clients who fail to show for an appointment or do not provide 24-hours notice may be assessed a no-show fee. OVME can be reached for canceling and rescheduling appointments vail telephone at 770.504.6000 or via email at hello@ovme.com voice messages can be left after hours. Appointment reminder emails and text messages are a courtesy and may not always occur. It is the client’s responsibility to ensure they are present for their scheduled appointment(s) or provide notice of their cancellation.

OVME REFUND POLICY 

OVME PROVIDES NO GUARANTEES AS TO OUTCOMES OR RESULTS. AS SUCH, THERE ARE NO REFUNDS PROVIDED FOR TREATMENTS PERFORMED IN ACCORDANCE WITH ESTABLISHED OVME TREATMENT PROTOCOLS AND PROCEDURES. IF YOU HAVE A QUESTION OR COMPLAINT ABOUT A TREATMENT, YOU SHOULD SPEAK WITH YOUR PROVIDER OR THE OVME STUDIO MANAGER, WHO WILL ESCALATE ANY SUCH QUESTIONS OR COMPLAINTS TO OVME MANAGEMENT, AS NECESSARY.

CONSENT FOR PHOTOGRAPHY FOR TREATMENT AND HEALTHCARE PURPOSES

I consent to have photographs, videotapes, digital or audio recordings, and any other means of recording or reproducing images or likeness (collectively, “Photography”), taken of me in connection with my treatment. I understand: (i) the Photography will be done to document and assist with my care and to assist with OVME’s health care operations;  (ii) the Photography or a portion of the Photography may become part of my medical record and therefore is protected, used and/or disclosed in accordance with OVME’s Privacy Policy which is available at www.ovme.com/pages/privacy-policy; (iii) OVME will own the Photography and I will not receive any payment for it; (iv) I will be allowed to access or view the Photography or to obtain copies of any portion of the Photography that becomes part of my medical record; and (v) any use of Photography for marketing or other non-medical/non-healthcare purposes will require a separate consent from me for OVME to use for such purposes.  

ACKNOWLEDGEMENT AND AGREEMENT

I understand this is an elective procedure and/or treatment, and I have voluntarily consented to treatment. The procedure and/or treatment has been fully explained to me, and I understand that I have the right to discontinue treatment at any time. I understand there are other alternatives to the procedures and/or treatments that I have volunteered for, and acknowledge that no guarantees have been made to me concerning my results.

I have informed the medical staff of any known allergies to drugs or other substances, and any past adverse reactions I have experienced. I have informed the medical staff of all medications and supplements I am currently taking. I am aware of possible side effects and drug interactions, and if I am prescribed medication by OVME, I understand that I must read and understand any disclosures included with that medication before using it.

YOU MUST BE AT LEAST 18 YEARS OF AGE OR OLDER TO RECEIVE THE TREATMENTS DESCRIBED  ABOVE IN THIS CONSENT.