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Informed Consent Regarding Use of Telemedicine / E-Visit Services

Date Of Last Revision: July 2019

This Consent is provided by CarePartners Pharmacy, LLC and its affiliates, including 4Romeo and 4Juliet entities, (collectively, “CPP,” “we,” “our,” or “us”)

Purpose

The purpose of this form is to provide you with information about telemedicine / e-visit and to obtain your informed consent to participate in a telemedicine / e-visit health service as part of your medical care.

Nature of telemedicine / e-visit

Telemedicine / e-visit involves the use of electronic communications to enable a health care provider and a patient at different locations to share medical information for the purpose of evaluation, diagnosis, consultation, or treatment of the patient. The delivery of healthcare via telemedicine / e-visit allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. For example, your telemedicine / e-visit encounter may include interaction through and with the use of the internet, recorded audio communications, physical examinations, medical imaging, medical tests, and diagnoses, as well as related technologies known as “store-and- forward.”

Benefits

The benefits of telemedicine / e-visit include improved access to medical services and care, including the expertise of specialists and consultants that may not otherwise be available to you. Telemedicine / e-visit also permits increased efficiency in evaluations, diagnoses, consultations, and treatment.

Potential Risks

The potential risks associated with the use of telemedicine / e-visit are rare, but include delays in medical evaluation and treatment due to equipment failures or information transmission deficiencies (such as poor image resolution); breach of privacy of protected health information due to security breaches or failures; and adverse drug interactions, allergic reactions, complications, or other errors due to patient’s failure to provide complete medical information or records.

Indemnification

YOU AGREE TO INDEMNIFY AND HOLD HARMLESS CarePartners Pharmacy LLC, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE / E-VISIT WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO CarePartners Pharmacy’s NEGLIGENCE.

Alternatives

Alternative methods of care may be available to you, such as in-person services. Your provider will explain any such options to you, and you may choose an alternative at any time.

Follow-up Care & Emergency Situations

In some situations, telemedicine / e-visit is not an appropriate method of care. If there is an urgent situation, if you have an adverse reaction, if a technical failure prevents you from communicating with your telemedicine provider, or if you believe telemedicine / e-visit will not provide sufficient safety and quality, you should contact CarePartners Pharmacy LLC at 866-832-7171 (Mon-Fri 8:30am to 5:30pm CST). If the contacts listed below are unavailable, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. If the situation is an emergency, call 911.

Your Privacy Rights

CarePartners Pharmacy LLC uses network and software security protocols to protect the confidentiality of your patient health information, including for example your medical record, EMR, imaging, and personal financial data. These protocols are designed to safeguard the data and to ensure its integrity against corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in CarePartners Pharmacy’s Notice of Privacy Practices.

By signing this form, I agree to the following

Telemedicine / e-visit is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider. I understand that I need to provide a full and accurate medical history, including any pre-existing conditions, to my telemedicine / e-visit provider so that my provider can accurately determine what services I need. I further understand that my provider will determine whether telemedicine / e-visit is appropriate for me at this time, based on the condition being diagnosed and/or treated. I understand that I may benefit from telemedicine / e-visit, but that results cannot be guaranteed.

My provider will inform me who will be present at the provider’s location during the telemedicine / e-visit service and I have the right to exclude anyone from being present, if I so choose. I further understand that I have the right to object to the use of a telemedicine / e-visit service without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled. If there are costs to me associated with my telemedicine / e-visit encounter, a health care professional will discuss those costs with me prior to the start of my session.

Further, I understand and agree that I must pay the full amount of the costs associated with this telemedicine / e-visit service, including any prescription I may receive, and I will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine / e-visit and I agree that CarePartners Pharmacy may provide my confidential personal health information to other medical providers who may be located in other areas, including on rare occasions to providers outside the State, as necessary. I have the right to inspect and obtain copies of all information received and recorded during any telemedicine / e-visit session, subject to the policies of the physicians, physician assistants, nurse practitioners and facilities involved in my care. I may be charged a fee for copies of my records in accordance with applicable State rules. I have read and understand the information above, and all of my questions have been answered to my satisfaction.

All photos and images used are licensed images and not actual patients unless expressed otherwise.

If you have a concern about a medical professional, you may contact the Medical Board in your state regarding your concerns.

I consent to a CarePartners Pharmacy LLC physician, physician assistant, or nurse practitioner to provide services o me via telemedicine / e-visit.

By clicking “I Agree”, I understand and consent to the foregoing acknowledgements and disclosures including CarePartners Pharmacy LLC Terms of Service and Notice of Privacy Practices.

You are free to obtain your prescription from any pharmacy of your choice. You are free to obtain your medical examination from another healthcare provider that is not associated with CarePartners Pharmacy LLC.

CarePartners Pharmacy will use its pharmacy to fulfill your order directly to your door. You are free to obtain your prescription from any pharmacy of your choice by contacting our support team. Further, for purposes of this informed consent, MY ACT OF CLICKING “I Agree” SHALL CONSTITUTE AND IS MY ELECTRONIC SIGNATURE.

Latisse® 3ml
Bimatoprost Opthamalic Solution

The 3 mL bottle comes with 70 sterile applicators which is a 4-week supply. This smaller bottle is typically used after the first 16-weeks and is applied 3-4 times a week to maintain the growth of your eyelashes. Latisse® is the only FDA-approved prescription topical solution that makes lashes longer, thicker, and more lush by prolonging the growth cycle of the individual lashes. You will see results in 4 weeks and the full effect of the treatment in approximately 16 weeks.

Important:

  • Do not use if pregnant, attempting to become pregnant, or at high risk of pregnancy. Tell your doctor if you are breastfeeding or if you have an eye infection, eye injury, or will be having eye surgery.
  • Do not use if allergic to Latisse®, bimatoprost or benzalkonium.
  • Do not apply Latisse® in your eye. This can stain your iris.
  • Do not apply Latisse® to your lower eye lashes.
  • Applying more than one drop of Latisse® or applying it multiple times a day will not increase eyelash growth.
  • Remove contact lenses prior to applying Latisse®. You may reinsert your contact lenses 15 minutes after application.
  • Do not allow the top of the bottle or applicator to touch fingers or any other unintended surface.
  • Only use the sterile applicators supplied with Latisse® to apply the product.

Caution:

  • Tell your doctor or seek medical help right away if you experience the symptoms of allergic reaction (rash/hives, swelling, and/or trouble breathing) or side effects become too irritating for continued use.
  • Let your doctor know about any changes in eyesight, any eye pain/irritation, sensitivity to light, or eye discharge.

Common Side Effects:

  • Eye irritation
  • Darkening of the eyelids where the solution is applied

How to Apply:

  • Make sure your face is clean and makeup-free
  • At night, apply one drop of solution to the applicator and sweep the applicator across the skin of the upper eyelid at the base of the eyelashes.
  • If there is excess solution on the eyelid, blot it with a tissue.
  • Dispose of the applicator after use on one eye. Repeat with a new sterile applicator on the other eye.
  • Remember, if you stop using Latisse®, lashes will gradually return to their previous appearance.

How To Store:

  • Keep this medication in the original container it came in, tightly closed, and out of reach of children and pets.
  • Store it at room temperature and away from excess heat and moisture.

Pharmacy law requires consultation be offered for those prescriptions that are new, have had a dose change, strength, or dosage form change, or have been transferred from another pharmacy. For drug consultation please contact: CarePartners Pharmacy (866) 396-0288. For HIPAA Privacy Policies, Terms & Conditions, and Consent to Treat; visit 4juliet.com

Latisse® 5ml
Bimatoprost Opthamalic Solution

The 5 mL bottle comes with 140 sterile applicators which is a 10-week supply. This larger bottle is great for first-time users who apply Latisse® daily for 16 weeks. Latisse® is the only FDA-approved prescription topical solution that makes lashes longer, thicker, and more lush by prolonging the growth cycle of the individual lashes. You will see results in 4 weeks and the full effect of the treatment in approximately 16 weeks.

Important:

  • Do not use if pregnant, attempting to become pregnant, or at high risk of pregnancy. Tell your doctor if you are breastfeeding or if you have an eye infection, eye injury, or will be having eye surgery.
  • Do not use if allergic to Latisse®, bimatoprost or benzalkonium.
  • Do not apply Latisse® in your eye. This can stain your iris.
  • Do not apply Latisse® to your lower eye lashes.
  • Applying more than one drop of Latisse® or applying it multiple times a day will not increase eyelash growth.
  • Remove contact lenses prior to applying Latisse®. You may reinsert your contact lenses 15 minutes after application.
  • Do not allow the top of the bottle or applicator to touch fingers or any other unintended surface.
  • Only use the sterile applicators supplied with Latisse® to apply the product.

Caution:

  • Tell your doctor or seek medical help right away if you experience the symptoms of allergic reaction (rash/hives, swelling, and/or trouble breathing) or side effects become too irritating for continued use.
  • Let your doctor know about any changes in eyesight, any eye pain/irritation, sensitivity to light, or eye discharge.

Common Side Effects:

  • Eye irritation
  • Darkening of the eyelids where the solution is applied

How to Apply:

  • Make sure your face is clean and makeup-free
  • At night, apply one drop of solution to the applicator and sweep the applicator across the skin of the upper eyelid at the base of the eyelashes.
  • If there is excess solution on the eyelid, blot it with a tissue.
  • Dispose of the applicator after use on one eye. Repeat with a new sterile applicator on the other eye.
  • Remember, if you stop using Latisse®, lashes will gradually return to their previous appearance.

How To Store:

  • Keep this medication in the original container it came in, tightly closed, and out of reach of children and pets.
  • Store it at room temperature and away from excess heat and moisture.

Pharmacy law requires consultation be offered for those prescriptions that are new, have had a dose change, strength, or dosage form change, or have been transferred from another pharmacy. For drug consultation please contact: CarePartners Pharmacy (866) 396-0288. For HIPAA Privacy Policies, Terms & Conditions, and Consent to Treat; visit 4juliet.com