Telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real-time.

I voluntarily request Clinica la Virgen de Guadalupe, physician(s) and such associates, residents, technical assistants and other health care providers.

Providers (i) may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform an in-person physical examination, and (iii) rely on information provided by me. I acknowledge that Clinica la Virgen de Guadalupe, providers´ advice, recommendations, and/or decision may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure. I understand and have been informed of alternatives to the treatment to which I now consent, and I have had the opportunity to ask questions and the questions I have asked with regard to this treatment, the associated risks, and possible alternatives, have all been answered to my satisfaction. I understand that no warranty or guarantee has been made to me as to a result or cure. Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the medical and/or diagnostic procedure(s) planned for me.

I realize that common to medical and/or diagnostic procedures is the potential for infection, blood clots in veins and lungs, excessive bleeding, allergic reactions, and even death. If Clinica la Virgen de Guadalupe providers determine that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented, or an in-person medical evaluation may be necessary. If I experience an urgent matter, such as a bad reaction to any treatment after a telemedicine session, I should alert my treating physician and, in the case of emergencies dial 911, or go to the nearest hospital emergency department.

To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of all and any part of my medical record (including oral information) to Clinica la Virgen de Guadalupe.

I understand and agree that the information I am authorizing to be released may include:

1) AIDS/HIV test results, diagnosis, treatment, and related information:

2) Drug screen results and information about drug and alcohol use and treatment;

3) Mental health information; and

4) Genetic information.

I understand that the disclosure of my medical information to Clinica la Virgen de Guadalupe providers, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images, and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering. I certify that this form has been fully explained to me, that I have read it or have had it read to me, and that I understand its contents.