Purpose of Virtual Care Membership

By signing this form, I consent to join the Virtual Primary Care Membership provided by Divine Med Spa & Clinic. I understand that this membership provides access to virtual healthcare services, which are delivered through secure electronic communications, including video consultations and telemedicine messaging. I agree to the following membership plan and its associated benefits as outlined by the clinic.

Scope of Services

I understand that the services provided under this membership include, but may not be limited to:

• Regular virtual consultations as specified in the membership plan.
• Prescription management and medication refills.
• Chronic condition management (for applicable plans).
• Wellness and health assessments.
• Ongoing communication with my healthcare provider via secure telemedicine tools.

 Limitations and Risks of Virtual Care

I acknowledge that telemedicine services have limitations, including:

• Telemedicine may not be suitable for all health concerns, and in some cases, I may be referred for an in-person consultation or emergency care.
• Technology issues (e.g., internet failures) may cause delays or disruptions in care.
• Some medical conditions may require diagnostic tests that cannot be performed virtually, necessitating in-person visits.

Fees and Payment

I understand that the membership fees for the virtual primary care plan are billed on a monthly basis. Fees for services outside the membership plan (e.g., lab work, specialist referrals) will be billed separately and are not covered under the membership.

• Membership Fee: per month
• I authorize Divine Med Spa & Clinic to charge my payment method for the recurring membership fee as per the selected plan.
• I am responsible for any charges not covered by my insurance or membership, including any applicable copayments or deductibles.

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Confidentiality and Data Security

I understand that all telemedicine consultations are conducted in compliance with HIPAA (Health Insurance Portability and Accountability Act) regulations to protect the privacy of my health information. Secure communication tools will be used for consultations, and all shared information will remain confidential. I will take steps to ensure I am in a private, secure location during virtual consultations.

Cancellation and Termination

I understand that I may cancel my membership at any time by providing [30 days] written notice to Divine Med Spa & Clinic. I acknowledge that if I cancel, I will still be responsible for any outstanding charges or fees incurred during my membership period. The clinic also reserves the right to terminate membership if payment is not received or if telemedicine is no longer appropriate for my care.

Patient Responsibilities

As a member, I agree to:

• Provide accurate and complete health information during consultations.
• Adhere to the treatment plans and recommendations provided by my healthcare provider.
• Schedule virtual consultations and follow-up visits as needed to manage my health effectively.

 Consent

By signing below, I confirm that I have read and understand the terms of the Virtual Primary Care Services Membership. I agree to participate in this membership under the conditions outlined above, and I consent to the use of telemedicine for my healthcare needs.

Patient Signature: _________________________________
Date: _________________________________
Provider Signature: _________________________________
Date: _________________________________