ONLINE INTERVIEW CONSENT, DISCLAIMER AND RELEASE FORM
I hereby attest that I have requested and authorized Courtney El-Zokm, M.D., P.A., (“Dr.
Courtney”) to perform a real time online interview with me as a preliminary discussion for possible future plastic surgery. Online interview/video conference and communications are provided as an alternative for the convenience of individuals seeking to speak with Dr. Courtney and for the purpose of exchanging preliminary information. This online interview/video conference and communication will serve to provide educational information regarding options for surgical procedures, but does not replace the pre-procedure, face-to-face evaluation and physical examination for final determination of my suitability for plastic surgery and a final treatment plan.
Following an in-person consultation and physical examination, Dr Courtney reserves the right to amend any information, assessment, or preliminary recommendation given during the prior online interview/video conference and related communications; and he may also decline to perform any surgery or procedure in his sole professional judgment. As such, any information provided during an online consult/video conference and communications further shall not be deemed to be a promise, guarantee, or agreement to provide services.
I authorize Dr. Courtney and his assigned, at his election, to obtain any information pertaining to my health including medical photography, surgical history, medical history, pathology, laboratory and diagnostic results from any and all treating health care providers. However, I understand that there may be a customary and reasonable charge for copying and handling my medical records and I agree to be solely responsible for such charges.
In addition, I understand and agree that:
______ (Initials) I certify that I am at least 18 years of age.
1. This online interview is a video link-up through online web services where visual images and voice are transmitted and may be recorded by Dr. Courtney. The consultation will require exposure of all physical features for which you seek evaluation and options for treatment. Although precautions are taken to protect the confidentiality, privacy and security of this information by preventing unauthorized review, I understand the risks and accept 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. Dr. Courtney shall not be held liable for any unauthorized access, use or disclosure of your personal health information, voice or images.
2. There are potential risks with the use of this technology requiring termination and rescheduling of this audio/video conference.
These include but are not limited to:
a. Interruption or disconnection of the audio/video link.
b. Video or audio that is not clear enough to meet the needs of the conference.
c. Electronic tampering.
3. The videoconference can be stopped at any time upon your request.
4. Dr. Courtney will have one of his medical team members present in the room with him during the entire consultation. I understand that I may have a witness with me during all or part of the consultation as well.
5. This online interview is solely based on the information provided by me and, in the absence of an in-person consultation and physical evaluation, Dr. Courtney may not be aware of certain facts or physical findings that may limit or affect his preliminary observation of my condition and options for surgical procedures.
6. An online interview is not intended to replace a full medical face-to-face evaluation and examination. Dr Courtney is limited to only verbal and visual communication, while tactile physical examination is absent, and will be required prior to the final evaluation, diagnosis and treatment plan determination. Accordingly, the information and options for procedures I will receive is limited and provisional.
7. Dr. Courtney is participating in an online interview to provide a preliminary opinion for proposed procedure options. Dr Courtney will not provide treatment unless, and until, a face to face evaluation is completed. Dr. Courtney does not assume any responsibility for use of his opinions by other health care providers for medical or surgical treatment. I understand that only my treating physician will remain responsible for my treatment.
8. I am responsible for all the expenses related to my online consult and accept Dr. Courtney’s non-refundable fee of $75. Should I elect surgical treatment by Dr. Courtney, the $75 will be applied to the surgical fee.
9. I have received a copy of Notice of Privacy Practices.
10. I solely assume the risk of the limitations set forth herein, and I further understand that no warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.
11. This online interview and preliminary discussion shall be construed under and governed by the laws of the State of Texas. The parties agree to bring any legal proceedings arising under this Agreement in a state court of competent jurisdiction within the State of Texas.
The paragraph shall not be construed to limit any other legal rights of the parties.
Disclaimer and Release: I hereby completely and irrevocably release Dr. Courtney, The Aesthetic Center For Plastic Surgery (ACPS) and their respective medical staff members, physicians and other healthcare professionals, administrators, officers, employees and directors of any and all errors and omissions, known or unknown, foreseen or unforeseen, knowingly or unknowingly, as well as all claims, actions or damages arising from or in connection with the online consult, conclusions or recommendations provided by Dr. Courtney. Furthermore, I agree that Dr. Courtney and ACPS have no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission. As a condition to receiving the online consult service, Ihave read and acknowledge that I have given this consent of my own free will.
I, the undersigned patient, do hereby understand and state that I agree to the above consents. I certify that I have read this consent or have had it read to me. I understand and agree to its contents.
By accepting and agreeing to these terms, I acknowledge and agree to assume the risks of the limitations set forth herein.
Interviewer Name (please print) _____________________________________________
Interviewer Signature: ______________________________Date___________________
Witness Signature: _________________________________Date __________________
Online Interview Consent, Disclaimer and Release Form
Aesthetic Center for Plastic Surgery, LLP
Courtney El-Zokm, M.D.