The Family Doctor Disclaimer for any electronic/telephonic advice or consultation process:

I hereby consent to engaging in telemedicine with a doctor from The Family Doctor Practice.

I understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical information, both orally and visually, to health care practitioners.

The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my treatment is confidential. I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my Provider, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

In addition, I understand that telemedicine based services and care may not be as complete as face-to-face services. I also understand that if my Provider believes I would be better served by another form of medical services (e.g. face-to-face services) I will be referred to a medical services provider who can provide such services in my area.

Finally, I understand that there are potential risks and benefits associated with any form of medical treatment, and that despite the efforts of my Provider, my condition may not be improve, and in some cases may even get worse. Therefore, I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured. I fully accept that the Treating physician / provider is only rendering an online or telephonic consult and does not necessarily assume any responsibility for my continued medical care or treatment.


I understand that this visit/encounter does not and should not replace a traditional doctor’s office visit; and therefore, I am proceeding with this tele-evaluation at my own risk and understanding. I also understand that should my condition or my responsible party’s be an emergency, I should contact local emergency response.

I certify that the information provided in this form of seeking medical assistance is true and accurate to the best of my ability. I also understand that omitting medical information or misinforming the assigned medical practitioner may result in an inaccurate diagnosis and treatment. I agree to disclose any pre-existing medical conditions or history openly and honestly with the practitioner who is assigned to assist me.

I have read and understand the information provided above. I understand that by responding to this service with a proof of payment hereby confirms my intention to seek the assistance I need and I will in no way hold The Family Doctor Practice or the assigned practitioner responsible as set out in this accepted disclaimer.

I hereby completely and irrevocably release The Family Doctor Practice and any of its practitioners 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 interaction, telephonic consultation, conclusions or recommendations provided. Furthermore, I agree that the The Family Doctor Practice has no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission.