Informed Consent 

Introduction:

I understand that I am agreeing to participate in telehealth services through the Easily platform. These telehealth services will be provided by the physicians, healthcare providers and any other professionals I sign up with (collectively, “Providers”) and are not provided by Easily. The purpose of these telehealth services is to evaluate my eligibility and for desensitization using Easily™ allergy toothpaste.

Telehealth is the practice of medicine that involves the use of electronic communications to diagnose or treat patients who are in different locations from their healthcare providers. Telehealth also enables healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. 

By executing this form, I, as patient or patient’s legal representative, consent to the utilization of telehealth technologies in the course of my medical treatment and authorize Providers to review and exchange medical information about me for the purpose of my treatment via telehealth. 

Expected Benefits of Telehealth Services:

  • Improved access to medical care by enabling a patient to remain in his/her location while the Provider consults and obtains test results at distant/other sites; and

  • More efficient medical evaluation and management.

Possible Risks of Telehealth Services:

As with any medical procedure, there are potential risks associated with the use of telehealth technologies in treating patients which may include, but may not be limited to:

  • Telehealth sessions could be disrupted or distorted by technical failures;

  • Lack of face to face and hands-on examination means that telehealth treatment is different from and can sometimes be more limited than in-person medical services; and

  • In rare cases, a lack of access to complete medical records may result in treatment delays, adverse drug interactions, allergic reactions, or other judgment errors.

Informed Consent for Telehealth Services 

By signing this form, I, acknowledge and affirm that I understand the following:

  • Not all conditions are appropriate for diagnosis and/or treatment via telehealth;

  • Alternatives to a telehealth consultation are available and I will have an opportunity to discuss them and concerns with Provider when initiating telehealth services;

  • I understand that I am responsible for information security on my device, including but not limited to, computer, tablet, or phone, and at my location.

  • Outcomes of this telehealth consultation cannot be guaranteed or assured;

  • I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment;

  • In the event of a medical emergency, I agree to call my local emergency dispatch (usually 911) for follow-up, in-person medical care, as appropriate;

  • In the event that communications are disrupted during telehealth, I will contact 424-327-4590 (call) or email at: info@easilyhealthcare.com for non-emergencies.

Informed Consent for Off-Label Use

I understand while the allergens that may be added to the Easily™ allergy toothpaste are approved by the Food and Drug Administration (FDA) for the immune cells under the skin, the addition of the allergens to the Easily™ allergy toothpaste is an off-label (non-FDA approved) use of this medication. I understand that off-label use is the physician practice of prescribing a drug for a purpose different from one of the indications for which the product is approved by the FDA. I also acknowledge that the Provider will review the use of this medication with me in detail, and answer my questions on the use of this medication. If appropriate, I request that the Provider proceed with the off-label prescription of Easily™ allergy toothpaste. 

By checking the Box containing “INFORMED CONSENT,” I, as Patient or Patient’s authorized legal representative, hereby give informed consent for the use of telehealth in Patient’s medical care under the terms and conditions described herein and verify that:

  • I have read the whole consent form and fully understands the information provided above regarding telehealth, including its benefits and risks, and the off-label use of the Easily™ allergy toothpaste; and

  • I understand I have the right to discuss the information contained herein with Provider and have all of my questions answered to my reasonable satisfaction to make a voluntary, informed decision regarding the use of telehealth services and the off-label use of the Easily™ allergy toothpaste.