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I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to have one of Top Notch Vitality LLC providers to provide health care services to me via telemedicine

I understand that I'm engaging in a telemedicine (telehealth) consultation.

I accept the risk of misdiagnoses

I hereby consent to and authorize Top Notch Vitality LLC providers (which may be a or combination of a Medical doctors, Physician Assistants or Nurse Practitioners) to administer and perform medical evaluation and treatment deemed necessary, and release Topnotchvitality.com of any legal responsibility

I understand that electronic communication technology will be used during online consultation, and such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties.

I understand that my healthcare information may be shared with Top Notch Vitality LLC medical team (MDs, PAs, NPs and Medical Assistants) and my pharmacy for the purpose of prescribing appropriate medication. The above mentioned people will all maintain confidentiality of the information obtained

Telemedicine carries the risk of misdiagnosis or delayed diagnosis, which could lead to patients not receiving the proper treatment or even receiving the wrong treatment. I understand these potential risks and willing to proceed with consultation with Top Notch Vitality LLC.

Due to the potential risk of misdiagnosis or delayed diagnosis, I understand and agree to seek immediate medical care if my symptoms do not improve within a timely manner (typically within 48 hours)

I understand that the treatment, therapy or recommendations provided by Top Notch Vitality LLC medical team is an initial and first-line approach and I agree to follow up with a doctor within the next 2-5 days for a re-evaluation if indicated.

I understand that the health care provider or I can discontinue the telemedicine consult/visit if it is felt that the electronic communication technology are not adequate for the situation

I understand that I have the right to withdraw my consent to the use of telemedicine at any time in the course of care. As long as the consent is in force, Top Notch Vitality LLC medical team may provide health care services to me via telemedicine without the need to sign another consent form

I have had the alternatives to a telemedicine consultation explained to me, and I'm choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be limited due to the fact that I will not be in the same room as my health care provider.

I accept Topnotchvitality.com model of telemedicine and I have visited www.topnotchvitality.com to learn how this model works, and their scope of practice.

You may contact us via email or phone with questions or concerns. (214-509-8715 or support@topnotchvitality.com)

By clicking the consent box I admit: That I have read or had this form read and/or had this form explained to me That I fully understand its contents including the risks and benefits of telemedicine. That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.