Consent All services provided by Synergy Health Network (SHD) are done via TeleHealth Technology. Telemedicine involves the use of communications to enable health care providers at sites remote from patients to provide consultative services. The communications systems used will incorporate reasonable security protocols to protect the confidentiality of patient information. I have read and understand the information provided above, and understand the risks and benefits of telemedicine, and by accepting these Terms. The scope of care will be at the sole discretion of the Provider who is treating you, with no guarantee of diagnosis, treatment, or prescription.
Purchase All sales are final and no refunds will be given. Paid consults can be rescheduled or transferred to another person.
Consent All services provided by Synergy Health Network (SHD) are done via TeleHealth Technology. Telemedicine involves the use of communications to enable health care providers at sites remote from patients to provide consultative services. The communications systems used will incorporate reasonable security protocols to protect the confidentiality of patient information. I have read and understand the information provided above, and understand the risks and benefits of telemedicine, and by accepting these Terms. The scope of care will be at the sole discretion of the Provider who is treating you, with no guarantee of diagnosis, treatment, or prescription. In the event the consent form fails to be properly signed you agree to the terms of service and consent form laid out here. By communicating with our care team and providers you and your family agree to all terms discussed here regardless of how the form is signed.
Patient Consent to the Use of Telemedicine I have read and understand the information provided above, and understand the risks and benefits of telemedicine, and by accepting these Terms I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.
COVID WAIVER THIS IS A LEGALLY BINDING DOCUMENT. In regards to the the 2019-2020 outbreak of the novel Coronavirus (“COVID19”), I agree, on my own behalf and any and all family members treated by Synergy Health DPC to hold harmless included (but not limited ) that i will not sue, and waive any claims against, past, current, and future officers, directors, employees, members, volunteers, contractors, representatives, parents, owners, affiliates, agents, successors, and assigns for any and all damages, injuries, losses, liability, claims, causes of action, litigation, or demands, including but not limited to those for personal injury, sickness, pain or death, as well as property damages and expenses, of any nature whatsoever, in any way related to COVID-19 in connection with my participation in the medications, treatments, and consultations.
ASSUMPTION OF RISKS Synergy Health DPC is not responsible in any manner for any risks related to COVID-19 in connection with any medications ordered as a result of an encounter with a provider. I further understand that COVID-19 is a highly contagious and dangerous disease, and that contact with the virus that causes COVID19 may result in significant personal injury or death. I am fully aware that (“Inherent Risks”) that cannot be eliminated regardless of the care taken to avoid such risks. Inherent Risks may include, but are not limited to, (1) the risk of coming into close contact with individuals or objects that may be carrying COVID-19; (2) the risk of transmitting or contracting COVID-19, directly or indirectly, to or from other individuals and objects; (3) injuries and complications ranging in severity from minor to catastrophic, including death, resulting directly or indirectly from COVID-19 or the treatment thereof. I assume all risks of taking any medications prescribed to me by company practitioners.I agree to hold harmless SHD and it practitioners from any claims of Malpractice. If my condition worsens I agree to notify SHD of any changes and agree to seek emergency medical care at a Hospital.
COVID-19 is not fully understood, and that contact with, or transmission of, COVID-19 may result in risks including but not limited to loss, personal injury, sickness, death, damage, pain and expense, the exact nature of which are not currently ascertainable, and all of which are to be considered Inherent Risks. I hereby voluntarily accept and assume all risk of loss, personal injury, sickness, death, damage, pain and expense to myself from any medications, treatments, or consultations from an encounter with Synergy Healthcare. This Agreement shall be binding on me, my heirs, executors, administrators, successors, and assigns. I expressly agree that this Agreement is intended to be as broad and inclusive as is permitted by applicable laws, and that if any portion of this Agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. This Agreement contains the entire understanding of the parties relating to the subject matter, and shall not be altered, amended, waived or supplemented in any manner whatsoever except by a written agreement signed by both parties hereto or their duly authorized representatives. This Agreement may be executed, made and delivered electronically. To the maximum extent permitted by applicable law and I, knowingly and voluntarily hereby waive any right to trial by jury with respect to such issue to the extent that any such right exists now or in the future. I certify that I have read this document and that I understand and agree to all of the foregoing information, terms, and conditions.
DISCLAIMER OF WARRANTIES; LIMITATION OF LIABILITY YOUR USE OF THE SERVICES IS AT YOUR OWN RISK. THE SERVICES ARE PROVIDED “AS IS” WITHOUT WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING WITHOUT LIMITATION WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON- INFRINGEMENT, OR OTHER VIOLATION OF RIGHTS. WE DO NOT WARRANT THE ADEQUACY, CURRENCY, ACCURACY, LIKELY RESULTS, OR COMPLETENESS OF THE SERVICES OR ANY THIRD-PARTY SITES LINKED TO OR FROM THE SERVICES, OR THAT THE FUNCTIONS PROVIDED WILL BE UNINTERRUPTED, VIRUS-FREE, OR ERROR-FREE. WE EXPRESSLY DISCLAIM ANY LIABILITY FOR ANY ERRORS OR OMISSIONS IN THE CONTENT INCLUDED IN THE SERVICES OR ANY THIRD-PARTY SITES LINKED TO OR FROM THE SERVICES. SOME JURISDICTIONS MAY NOT ALLOW THE EXCLUSION OF IMPLIED WARRANTIES, SO SOME OF THE ABOVE EXCLUSIONS MAY NOT APPLY TO YOU.
INDEMNIFICATION YOU AGREE TO INDEMNIFY, DEFEND AND HOLD US AND OUR PARENTS, SUBSIDIARIES, AFFILIATES, LICENSORS, SUPPLIERS AND THEIR DIRECTORS, OFFICERS, AFFILIATES, SUBCONTRACTORS, EMPLOYEES, AGENTS, AND ASSIGNS HARMLESS FROM AND AGAINST ANY AND ALL LOSS, COSTS, EXPENSES (INCLUDING REASONABLE ATTORNEYS’ FEES AND EXPENSES), CLAIMS, DAMAGES AND LIABILITIES RELATED TO OR ASSOCIATED WITH YOUR USE OF THE SERVICES AND ANY ALLEGED VIOLATION BY YOU OF THESE TERMS. WE RESERVE THE RIGHT TO ASSUME THE EXCLUSIVE DEFENSE OF ANY CLAIM FOR WHICH WE ARE ENTITLED TO INDEMNIFICATION UNDER THIS SECTION. IN SUCH EVENT, YOU SHALL PROVIDE US WITH SUCH COOPERATION AS WE REASONABLY REQUEST.
I hereby certify that I am at least 18 years of age and am qualified under the laws of my state to make medical decisions on my own behalf. I acknowledge information is conditional upon the truthfulness of my age. You hereby certify that you are physically located in the State you have entered as your current location on the Services
Payment Authorization By providing a credit card or other payment method accepted by the company you are expressly agreeing that we are authorized to charge to the Payment Method any fees for your use of the Services, together with any applicable taxes. You agree that authorizations to charge your Payment Method remains effect until you cancel it in writing, and you agree to notify the company of any changes to your Payment Method. You certify that you are an authorized user of the Payment Method and will not dispute charges for the Services. You acknowledge that the origination of ACH transactions to your account must comply with applicable provisions of U.S. law. In the case of an ACH transaction rejected for insufficient funds, Company may at its discretion attempt to process the charge again at any time within 30 days.
When scheduling a visit with a Provider using the Services, you will be required to provide a Payment Method. If you choose to cancel your scheduled appointment, you must do so at least 24 hours in advance of the scheduled appointment time. Should you choose to cancel your scheduled appointment within 24 hours of the scheduled appointment time,