Dr. Mona Saleh- Elgredly Follow up Request-ProvisRudd Endoscopy

First Name

Last Name

Email

Phone Number

Reason for Follow-up:

Please provide details of the request:

Best day for call back

Best time for call back

Morning

Afternoon

Evening

I understand that the doctor will call me in a priority sequence and my preferred date and time may not be met

Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.

I agree and consent to receive care virtually via telephone call [Informed Telemedicine Consent].

Informed Telemedicine Consent

I understand that due to constraints imposed by the current COVID-19 pandemic, part or all of my care may be provided through telemedicine, which allows providers at a remote location to assess me and devise a treatment plan through electronic or other means of communication.
I understand the purpose of the telemedicine encounter is to maintain the standard of care and triage my condition appropriately.
I understand the need for telemedicine during this pandemic in order to maintain social and physical distancing, and that the benefits of telemedicine include, but are not limited to, easier and quicker access to providers, even at a distance. I understand that the risks of telemedicine include, but are not limited to, inability of the healthcare provider to examine or visualize me, insufficiency or delays in information capable of being transmitted and, therefore, inability to properly or timely treat a condition. In rare instances, security breaches could take place, causing a breach of privacy.
I understand PES has technical protocols in place to protect my privacy. I understand that being treated by a practitioner who is not able to examine or visualize me or who may have incomplete access to my complete medical history could result in adverse drug reactions or interactions or other judgment errors. I understand that these are not all of the risks, but just some of the material risks.
I acknowledge and agree that no guarantee or assurances have been made to me concerning the results of telemedicine. I have been informed of the alternatives to telemedicine and consent to proceed with a telemedicine consultation. I understand that other individuals may be present to assist with the telemedicine encounter.
I will be informed of the identity of all parties who are present at the distant and local site, and I understand I have the right to exclude anyone from either site or terminate the visit at any time.
I understand that my provider or I may discontinue the telemedicine visit at any time, for any reason,including if it is felt that the connection is not adequate for the situation. Withdrawing my consent to the use of telemedicine will not affect my right to future care or treatment. I have had all of my questions answered to my satisfaction, and consent to participate in a telemedicine consultation.