I consent to have a telemedicine visit today with Cheresse Nadir, APRN. By checking/agreeing to this teleconsent, I acknowledge telemedicine visits are limited due to the inability to perform a physical exam. No imaging orders. At any time the provider feels an in-person visit is necessary, the visit can be concluded and I may be directed to an in -person clinic. I agree to follow providers recommendations to avoid delay in treatment or diagnosis.
If this is a medical emergency- CALL 911 NOW. Use of this virtual clinic for emergent conditions/symptoms is not appropriate.
I agree to provide correct and up to date medical information to the best of my knowledge. I will provide correct personal identification, insurance information (if applicable) and payment information. I understand that by withholding information about my medical/social history, my medical care may lead to negative outcomes/side effects, etc. For the best care, I understand I need to provide up to date and honest information in order to get the safest, best medical care.
I understand that prescriptions will be send if appropriate by provider but not guaranteed. Treatment will be based on exam. NO controlled medications are prescribed through VirtualNP, LLC clinic.
Cancellation Policy:
The patient and/or the provider has the right to cancel the telemedicine visit at any time.
No refunds will be provided if the patient cancels the appointment.
Refund Policy:
No refunds.
I confirm that I am currently PHYSICALLY located in one of the following states during the telemedicine visit: AZ,FL, ID, IA, LA, NH, NV, WA, WY.
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