Terms and Conditions Concerning Telemedicine at Frontline Medical PLLC “Frontline Medical” (Doing Business as Altius Performance Medicine) I understand that my healthcare provider wishes for me to engage in a telemedicine consultation. I am confirming that I will be located in the same State as described in my Intake Form prior to my appointment. I consent to receive medical/health services through the Frontline Medical telemedicine platform.
I consent to participate in a telemedicine consultation which includes an intake process, triage, communications, medical evaluation, diagnosis, treatment and/or other services rendered through the use of electronic communications (i.e. video connections, zoom, phone call) with Frontline Medical’s staff and licensed providers who are located at a different site(s) (off-site providers). I understand the potential benefits and risks of participation in the telemedicine program. I understand not all care is able to be provided through telemedicine by Frontline Medical. I acknowledge that I can access my medical records by request through contacting Frontline Medical at 210-888-9657 or by using the contact information provided on Frontline Medical’s website(s). https://frontlinealternative.com/ https://frontlinemedspa.com/ I understand that the telemedicine technology used for consultation will not be the same as a direct, in-person provider visit due to the fact that I will not be in the same room as my healthcare provider. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telemedicine consult/visit if it is felt that the connections are not adequate for the situation. I understand that if others are present during the consultation, other than my healthcare provider, they will maintain confidentiality regarding the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history or physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and/or (3) terminate the consultation at any time. I understand the alternatives to a telemedicine consultation and voluntarily choose to participate in a telemedicine consultation.
I am an adult (at least 18 years of age). I am competent to use the telemedicine services and have access to technology required for telemedicine consultations as offered by Frontline Medical. I understand that the consulting medical provider at Frontline Medical may or may not prescribe treatment based on my medical history, assessment, and information provided. I understand failure to provide accurate, truthful, and complete information to my consulting healthcare provider may result in inappropriate treatment which could subsequently lead to harmful outcomes or reduce the effectiveness of treatment. I agree to respond to each question truthfully and accurately. I agree to fully disclose all information concerning my health and medical history including current medications and dosing relevant to my current medical conditions. I have been seen by a primary care provider and have had a comprehensive, in-person physical examination and/or medical history evaluation within 12 months of requesting services from Frontline Medical.
I agree to undergo a telemedicine physical examination every year with my healthcare provider at Frontline Medicine to ensure my request for treatment is appropriate, and to inform my personal healthcare provider about the products obtained through Frontline Medical. I agree to contact my healthcare provider at Frontline Medical if I have questions, difficulties, or complications with recommended treatment(s). I agree to make my healthcare provider at Frontline Medical aware of any changes to my medical condition. I understand that I will be given the opportunity to ask any and all questions regarding any tests, procedures, or medication(s) that may have been prescribed to me.
I understand that there are risks associated with taking any medication including the risks involved with self-administered injections of medications. By signing this form, I certify: * I have read, had this form read, and/or had this form explained to me. * I fully understand its contents and agree with its contents including the risks and benefits of the recommended treatment(s). Signature [clear] Use your mouse or finger to draw your signature above Patient Authorization for Delivery of Medications Prescribed by Frontline Medical PLLC (Frontline Medical) I hereby authorize the clinic’s staff on duty to act on my behalf to coordinate medication delivery from the clinic’s dispensing pharmacy and/or physician to me as prescribed by my medical provider. Any orders delivered damaged or incomplete must be reported to Frontline Medical within 24 hours of delivery along with pictures of damaged package/product which must be sent to [email protected]. Frontline Medical is not financially responsible or liable for lost or stolen items once delivered. Once items have been scanned as delivered to the patient’s address, it is the patient’s sole responsibility to report any missing or stolen packages to Frontline Medical within 24 hours of delivery date. Any packages returned for an INCOMPLETE/ INCORRECT address can be shipped again at the patient’s expense. No Guarantee of Services Frontline Medical PLLC (Frontline Medical) does not guarantee that any services or medications will be provided to you until you have undergone the full initial sign up process and consultation by our licensed providers. At the provider’s sole discretion, you will be provided medications and/or services. Frontline Medical requires you to have an annual consultation with our provider and biannual lab work done. Additional lab work can be requested by the provider or patient at any time. General Payment Disclosure and Refund Policy Frontline Medical PLLC (Frontline Medical) reserves the right to maintain a NO RETURN and NO REFUND policy. I understand the cost of the consultation and prescribed medications can vary depending on the treatment protocol which will be discussed and agreed upon with each patient prior to billing. I understand Frontline Medical is a direct payment clinic that does not accept medical insurance. I understand Frontline Medical will not save card/payment information unless verbally directed to save payment information.
