Telehealth and IM Consent

CONSENT TO Ivím TELEHEALTH CONSULTATION

Updated January 1, 2023

1. PURPOSE: Ivím Telehealth Consultation connects you as the patient or the patient’s representative, and an assigned provider, who is a qualified health professional in a different location, for a IViM Telehealth consultation. The provider will evaluate and guide your personal health goals with use of our intramuscular compound supplements. The purpose of this form is to confirm patient consent to participate in the Ivím Telehealth consultation.
2. NATURE OF TELEMEDICINE CONSULTATION:
   During an Ivím Telehealth consultation: A well-qualified health professional will, using interactive video, audio and telecommunications technology, go through the patient medical history and symptoms information with you and, if needed, do a visual examination by video.
   1. Tests and/or medication may be prescribed, although no narcotic drugs nor other controlled substances will be prescribed.
   2. If the health professional determines the medical condition identified requires something more medically than can be done in an Ivím Telehealth consultation, you will need to make an in person appointment with the health professional of your choice, or, if we sense it is an emergency, we will notify you to call 911 immediately.
3. BENEFITS AND RISKS: Services provided by Ivím Telehealth consultation have certain benefits, such as the ability to obtain timely access to expertise of a provider at distant site. However, because it involves telecommunications technology and people located at distant locations, any telehealth potentially has some added risks, including, but not limited to delays in medical evaluation and treatment due to signal interruptions or other technical difficulties
4. MEDICAL INFORMATION AND RECORDS: All existing laws regarding privacy and security of health information and access to medical information and copies of patient medical records apply to the Ivím Telehealth consultation and the audio and video information transmitted, received and stored electronically as part of the service. You have been furnished Our Notice of Privacy Practices, which explains these issues in greater detail.
5. RIGHTS: You may prospectively withhold or withdraw consent to the Ivím Telehealth consultation at any time before or during the consultation without affecting the right to future patient care or treatment.
6. NO PROMISES OF RESULT. While the health professional will try to give you his/her judgment as to what the patient can likely expect healthwise after the consultation, because health care practice has unavoidable uncertainties, no promises of specific results or outcome can or will be made.
7. DISPUTES: Any dispute arising from an Ivím Telehealth consultation will be resolved in Howell, Michigan, and Michigan law will apply.
8. COPIES SERVE AS ORIGINALS. Legible copies in paper or electronic format of this form and any signature on it, shall be deemed to be originals and fully relied upon for all purposes

CONSENT TO Ivím TUTORIAL VIDEO FOR INTRAMULSCULAR/SUBCUTANEOUS INJECTION TRAINING

Updated January 1, 2023

1. PURPOSE: The Ivím Clinic has provided an intramuscular injection training video for training of nonmedical personnel on how to perform self-injection of intramuscular compounds. This tutorial video is to be utilized to train patients on how to properly perform self injection of intramuscular compounds provided by the Ivím clinic and prescribed during the Ivím Telehealth consultation.
2. NATURE OF INTRAMUSCULAR INJECTION TRAINING VIDEO:
   The Ivím intramuscular injection training video will provide:
   1. Accurate instructions on supplies needed for self-injection which will be provided with your prescription
   2. Information on what it means to perform an intramuscular injection
   3. Information and demonstration of how you can perform self-administered intramuscular injection
3. Review of common issues that may occur during intramuscular injection and how to manage them
4. Review of contraindications to (reasons not to use) intramuscular injection
5. BENEFITS AND RISKS: Since we are not physically located in your community, the Ivím Telehealth consultation and guidance on performing a self-injection are being provided to you using interactive video, audio, and telecommunications. The Ivím tutorial video on how to perform intramuscular self-injection serves as the training video provided to the patient in order to train patients on how to perform self-injection of intramuscular compounds. While the benefit of this is being able to provide remote training without requiring the presence of a provider at a specific location, this does come with some potential risk. Risks of any injection include, but are not limited to: tingling or numbness, redness, swelling, pain, bruising, prolonged bleeding, skin irritation, skin infection at the site, or issues with the devices used for self-administration. Major but very rare complications include: allergic reactions including anaphylactic reaction and major adverse skin reactions/wound complications. You can minimize the risks by carefully reviewing the Ivím intermuscular injection Tutorial.
6. RIGHTS: You may withhold or withdraw consent to perform training for intramuscular injection by not viewing the Ivím intramuscular injection training video at any time before or during the consultation without affecting the right to future patient care or treatment. Ivím clinic providers retain the right to refuse prescribing intramuscular injections if the training is not completed. By not completing the intramuscular training process, the patient increases all those risks of performing self-injection of intramuscular compounds listed above and we cannot support you doing that.
7. NO PROMISES OF RESULT: While Ivím providers will try to give you his/her judgment as to what thepatient can likely expect healthwise after the consultation and training video, because health carepractice has unavoidable uncertainties, no promises of specific results or outcome can or will be made.
8. DISPUTES: Any dispute arising from an Ivím Telehealth consultation will be resolved in the Livingston County Court in Howell, Michigan, and Michigan law will apply.
9. WHAT ACCEPTING THIS CONSENT MEANS—YOUR ACCEPTANCE AND AGREEMENT:

Statement for the Patient. I have read and accept the terms of the Ivím telehealth consultation and the IViM intramuscular injection tutorial training video above (1 through 8) as well as IvímT utorial Training Video above (1 through 6) and understand the benefits and risks of the Ivím Telehealth consultation and IViM intramuscular injection training video. I have had my questions about the service and the self-injection process answered. I confirm that no patient emergency condition is present and consent to participating in the Ivím Telehealth consultation and intramuscular injection training video as described in this consent.