The best prices and free delivery are only guaranteed through Alpha’s pharmacy. Receiving your prescription may take an additional 2-3 days when using another pharmacy.
|Patient’s Legal Name|
|Date of birth|
|Date of consent||09/18/2019|
|Telemedicine Services Provider||Foster Medical - (859)-300-6006|
Welcome to Alpha! Your health is important to us. Please carefully review the information below. This document is intended to inform you of the risks associated with telemedicine services. Your understanding of Telemedicine is important before any services can be provided to you.
Telemedicine is a method for providing efficient medical care services using an interactive telecommunications system (e.g. the Internet or by phone) by a physician or practitioner who is licensed under State law to provide medical services to a patient in a location other than the location of the licensed medical practitioner (“Telemedicine Services”) . Telemedicine Services uses digital and electronic communications to enable a health care provider and patient to share medical information in order to evaluate, diagnose, consult, or treat the patient. The delivery of telemedicine healthcare allows the patient and medical care provider to establish a relationship from anywhere, independent of their location. In order to use the Telemedicine Services, you must have and maintain access to an interactive telecommunications system.
Telemedicine Services provides improved access to medical services and care. This includes the expertise of specialists that may not be available for a face-to-face consultations. Telemedicine Services can also provide efficient care in evaluations, medical consultations, diagnoses, and treatment, leading to improved access to medical care.
Telemedicine Services offers an efficient way for medical care providers and patients to communicate and there are few risks associated with the use of Telemedicine Services. Potential risks include:
YOUR USE OF THE TELEMEDICINE SERVICES IS VOLUNTARY. YOU AGREE TO INDEMNIFY & HOLD HARMLESS ALPHA MD, LLC, THE TELEMEDICINE SERVICES PROVIDER, AND THEIR RESPECTIVE MEMBERS, MANAGERS, REPRESENTATIVES, DIRECTORS, AGENTS, EMPLOYEES, PARENTS, SHAREHOLDERS, PREDECESSORS, OFFICERS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIMS, OR DEMANDS BROUGHT BY ANY PARTY WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE SERVICES WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO ALPHA MD, LLC OR THE TELEMEDICINE SERVICES PROVIDER’S NEGLIGENCE.
If you are experiencing a medical emergency call 911 or seek care at an emergency room facility or other provider equipped to deliver urgent care.
If there is an urgent situation in which you experience an adverse reaction, or technical difficulties prevent you from communicating with the Telemedicine Services Provider, or if you no longer wish to use Telemedicine Services, stop using the Telemedicine Services and please contact the Telemedicine Services Provider at the number listed above.
By signing this form, I acknowledge that I have read and understand the risks and benefits of participating in Telemedicine Services and I have received answers to all of my questions to my satisfaction. I further acknowledge and agree that:
By clicking “I Agree” below, I understand and agree to the foregoing acknowledgements and disclosures including Telemedicine Services Provider’s Terms of Service and Notice of Privacy Practices. Alpha MD, LLC has a commercial and financial relationship with Telemedicine Services Provider I understand that I am free to obtain medical examination and advice from another healthcare provider that is not associated with Alpha MD, LLC at any time. I understand that Alpha MD, LLC will use its partner pharmacy to fulfill my prescription order(s), if any as a convenience to me. I understand that I am free to obtain my prescription from a pharmacy of my choice.
BY CLICKING “I Agree” I CONSENT AND PROVIDE MY ELECTRONIC SIGNATURE.