CONSENT FOR TREATMENT
- I understand the nature of my medical condition and the reasons for prescribing the specific medication(s) have been explained to me in terms I understand.
- Alternatives treatments and their benefits and risks, and the anticipated length of the treatment have been explained to me.
- I understand and accept the possible side effects of the specific/prescribed psychotropic medications.
- I understand and accept additional possible side effects that may occur when psychotropic medications are taken for extended periods (over three months) include persistent, involuntary movements of the face, mouth, or extremities (hands/feet). These symptoms are potentially reversible and may appear after the medications have been discontinued.
- I understand that psychotropic medication may include certain lab tests on regular required basis.
- I have informed the physician all of my known allergies to the best of my knowledge.
- I have informed the doctor of all medications I am currently taking, including prescriptions, over-the-counter remedies, herbal therapies and supplements and any other recreational drugs or alcohol use to best of my knowledge.
- I have been advised whether I should avoid drinking alcoholic beverages and consuming any or all of these medications while taking psychotropic medication(s).
- I am aware and accept that no guarantee about the results of the treatment have been made.
- I have been advised of the probable consequences of declining recommended or alternative therapies.
The doctor has answered all of my questions regarding proposed/recommended treatment.
I certify that I have read and understand this treatment agreement and that all blanks were filled in prior to my acknowledgment (signature).
I authorize and direct Instic Health LLC and/or it’s provider to provide treatment with proposed/recommended treatment.
Telepsychiatry means providing psychiatric services through interactive HIPAA compliant video conferencing software where provider and patient are not physically at the same location.
- I understand privacy and confidentiality law of protecting my health information also applies to telepsychiatry.
- I understand that video conferencing used by Instic Health LLC is HIPAA compliant.
- I have right to withdraw my consent to use telepsychiatry at any time by informing Instic Health providers.
- I understand that Instic Health providers has the right withdraw consent to the use of telepsychiatry.
- I understand that I will not record or take pictures during my session with any of the Instic Health providers.
- I will inform Instic Health providers if any other person can hear my telepsychiatry session.
- I understand I must be a resident of Florida and reside in Florida to eligible for telepsychiatry offered by Instic Health providers.
I have read and understand above information and authorize Instic Health providers to use telepsychiatry for diagnosis and treatment.