Virtual Visit Consent

Clarity Eye Center Virtual Visit Consent

I have been asked by my healthcare provider to take part in a virtual consultation with Clarity Eye Center (CEC) and its physicians, associates, technical assistants, and others deemed necessary to assist in my medical care through a virtual consultation.

I understand the follwing:

1. The purpose is to assess and treat my medical condition. 2. The virtual consult is done through a two-way video link-up whereby the physician or other health provider at CEC can see my image on the screen and hear my voice. However, unlike a traditional medical consult, the physician or other health provider does not have the use of the other senses such as touch or smell; and it may not be equal to a face-to-face visit. 3. Since the virtual consultants practice in a different location and do not have the opportunity to meet with me face-to-face, they must rely on information provided by me or my onsite healthcare providers. CEC Providers and affiliated virtual consultants can not be responsible for advice, recommendations and/or decisions based on incomplete or inaccurate information provided by me or others. 4. I can ask questions and seek clarification of the procedures and virtual technology. 5. I can ask that the virtual exam and/or videoconference be stopped at any time. 6. I know there are potential risks with the use of this new technology. These include but are not limited to: • Interruption of the audio/video link. • Disconnection of the audio/video link • A picture that is not clear enough to meet the needs of the consultation • Electronic tampering. If any of these risks occur, the procedure might need to be stopped. 7. The consultation may be viewed by medical and non-medical persons for evaluation, informational, quality, or technical purposes. 8. I understand the examination may be videotaped for internal quality review or as might be required by my health coverage plan, however the video images will only be used for those purposes.
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