PROVIDERS USING WEEKEND HEALTH DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM AND SHOULD NOT PROCEED WITH USING THE WEEKEND HEALTH SERVICES.
IF YOU ARE CONTEMPLATING SUICIDE, CONTACT 911 OR THE NATIONAL SUICIDE PREVENTION LINE AT 1-800-273-TALK (8255).
You are receiving and acknowledging this Telehealth Informed Consent because you or a minor under your authority is seeking Health Care Services utilizing telehealth technologies by Weekend Health, Inc. (“Weekend Health”, “we”, “us” or “our”), facilitated through the joinsequence.com website and other websites which are owned or operated by Weekend Health or its affiliates (the “Site”), other digital interfaces and properties (e.g., mobile applications) owned, controlled by, or made available to you by Weekend Health (“Mobile App”), and other online or mobile-enabled technology, digital tools and other services and products provided by Weekend Health and its affiliates (together with the Site and Mobile App, the “Services”).
By creating an account, starting a consult, clicking “I consent to telehealth,” checking a related box to signify your acceptance or using any other acceptance protocol presented through the Weekend Health Services you indicate that you have reviewed the risks as described herein of receiving services utilizing telehealth technologies and consent to receiving the services.
A record of this Telehealth Informed Consent is maintained in the files and records of the applicable Provider delivering your services, and your on-going participation in services by Weekend Health using telehealth technologies serves as an on-going acknowledgement of your acceptance of this Telehealth Informed Consent and updates at such time the representations you provide herein.
What is Telehealth?
Telehealth involves the delivery of health and wellness services using electronic communications, information technology, or other means between a licensed, certified, or registered health care professional at one location and a patient in another location about a clinical matter with or without the support of an intermediary extender. Telehealth may be used for diagnosis, treatment, follow-up, and/or health and wellness education. These telehealth services may involve various modalities, including asynchronous interactions, real-time video and audio encounters and interactive audio with store and forward. This “Telehealth Informed Consent” informs the patient or guardian (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of utilizing telehealth to meet your health and wellness needs.
What are the Possible Benefits of Telehealth?
It can be easier and more efficient for you to access health and wellness services. You can obtain health and wellness services at times that are convenient for you without the necessity of an in-office appointment, including follow-up care related to your treatment. If you need follow-up care, please contact us through the Weekend Health call center +1 (831) 484-7713. Your Provider may be a physician, a nurse practitioner or a physician assistant.
What are the Possible Risks of Telehealth?
Information transmitted to your health professional may not be sufficient to allow for appropriate health or wellness services to meet your particular need. Some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. The technology necessary to interact with your health professional may fail and delay your services. If a technical failure prevents you from communicating with your Providers, you should call the following number: +1 (831) 484-7713. As all data exchanged is in a digital format, a data breach enables increased access to your health data. In rare events, a lack of access to complete medical records, and/or the quality of transmitted data could result in adverse drug interactions, allergic reactions, and/or other clinical judgment errors. You may stop or decline any on-going clinical care made available by Weekend Health using telehealth technologies at any time, although you acknowledge that a cancellation fee may apply and Weekend Health has no obligation for your on-going care or selection of separate health care services in such circumstances.
By accepting this Telehealth Informed Consent, you acknowledge you understand and consent to the following:
1. I have reviewed this Telehealth Informed Consent carefully, and understand there are risks, limitations, and benefits of utilizing telehealth.
2. I understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my health information.
3. In some cases, my Provider may be a nurse practitioner or physician assistant and not a physician.
4. Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies and/or for language translation assistance, if requested. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.
5. I understand that information I provide as part of any telehealth offering is viewed as accurate, true, and complete. I understand that I can log into my patient account https://app.joinsequence.com any time to access, amend, or review my health information.
6. There is no guarantee that I will be given a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. I understand that while the use of telehealth may provide benefits to me, no such benefits or specific results can be guaranteed and my condition may not improve.
7. I understand there is a risk of technical failures during the telehealth encounter beyond the control of my Provider(s). I AGREE TO HOLD HARMLESS WEEKEND HEALTH AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
8. I understand the Weekend Health Services make available a specific set of services and I may need to seek other resources for my other health needs. There is no guarantee that I will be treated by a Provider. My Provider reserves the right to deny care for any reason if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth is not medically or ethically appropriate. I understand that the Providers, and not Weekend Health, are responsible for the quality and appropriateness of the care they render to me and make all decisions regarding clinical care in their independent discretion without the influence of Weekend Health. I agree to only seek relief against the Provider for any liabilities pertaining to medical or clinical issues arising as a direct result of medical or clinical services accessed through Weekend Health.
9. I understand that I have the opportunity to discuss the use of telehealth, including the Health Care services, with my Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. I have the right to withdraw my consent to the use of telehealth in the course of my care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who provide Health Care services via the Weekend Health do not offer in-person treatment.
10. I understand that I have access to my medical record pertaining to the Health Care services of Providers utilizing the Weekend Health Services in accordance with applicable laws and regulations and that my primary care provider, or other treating provider, may obtain copies of my health and wellness information with my advance consent and direction that I may or may not provide to Weekend Health in my sole discretion.
11. I understand that while Weekend Health may make available access to pharmacy or diagnostic lab services that are coordinated with the Health Care Services, I am able to request any pharmacy or lab of my preference.
Additional State-Specific Disclosures: The following disclosures apply to users accessing the Weekend Health Services for the purposes of participating in a telehealth visit as required by the states listed below:
Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://medicalboard.iowa.gov/consumers/filing-complaint.
Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://kbml.ky.gov/grievances/Pages/default.aspx.
Maine: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://www.maine.gov/md/discipline/file-complaint.html.
Oregon: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://www.oregon.gov/omb/investigations/pages/how-to-file-a-complaint.aspx.
Rhode Island: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: https://health.ri.gov/complaints/.
Texas: I have been informed of the following notice:
NOTICE CONCERNING COMPLAINTS- Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.
AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us
Vermont: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; or Board of Osteopathic Examiners can be found at: https://www.sec.state.vt.us/professional-regulation/file-a-complaint-employer-mandatory-reporting.aspx.
Wyoming: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here: http://wyomedboard.wyo.gov/consumers/file-a-complaint.
 “Providers” includes all professional entities and individual licensed clinical professionals affiliated with Weekend Health and utilizing the Services to make available clinical care to patients also utilizing the Services.