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DEFINITION OF TELEMEDICINE: Telemedicine is a type of medical service provided by a healthcare provider who is not physically present with the patient. The healthcare provider instead communicates and interacts with the patient through phone, video, and/or email to attempt to diagnose and treat non-emergent medical conditions. Telemedicine is an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care remains with a primary care physician in person.


I agree to participate in a consultation using Starks Medical, PLLC and agree to receive services via telemedicine. I confirm that I am of sound mind and can make appropriate medical decisions. If I am consenting on behalf of a minor, incapacitated, or otherwise legally dependent patient, I certify that I have legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.


I agree that I am 18 years or older. I understand that no one under the age of 18 can have a consultation without a parent or guardian’s consent and that parent or guardian must be present during the entire telemedicine visit.


I authorize the electronic transmission of my/the patient’s medical information and/or videoconference session so that it can be viewed by a healthcare provider and other persons involved in my/the patient’s medical care.


I understand that I can withdraw my consent at any time by ending the telemedicine session and my right to future telemedicine consultations will not be affected. I should immediately pursue a face-to-face consultation with another medical provider.


I understand that I/the patient will not be in the same location or room as the medical provider and that all interactions with the medical provider will be through phone, electronic messaging, and/or video. I understand the inability to have direct, physical contact with a medical provider and inability to perform any diagnostic testing (such as blood, urine, other lab, and imaging tests) may result in adverse drug interactions, allergic reactions, incorrect diagnosis, or other judgement errors.


I understand there is no guarantee that this telemedicine session will eliminate the need for me/the patient to see a primary care physician, emergency physician, or specialty physician in person. I understand in some instances the medical provider providing telemedicine consultation may deem it necessary for me/the patient to be evaluated by an in-person physician. 


I understand the potential risks of telemedicine which may include delays in evaluation, delays in treatment, and medical errors due to technical difficulties, distortion of images, unauthorized access, lack of in-person physical exam, and lack of access to complete medical information.


I agree to report my/the patient’s location accurately to the medical provider and acknowledge I/the patient must be in the state of Texas at time of consultation.


I understand that Starks Medical, PLLC providers will not prescribe controlled medications such as opioids, benzodiazepines, ADHD stimulants, etc.


I understand that controlled medications will not be prescribed, nor is there any guarantee that I will be given a prescription at all.


I understand Starks Medical, PLLC does not provide evaluation or treatment for life or limb threatening emergencies. If you think you or the patient is having a medical emergency, you must immediately call 911 or go to the nearest emergency department.


By checking the Box on the Booking Page containing "I agree to the Telemedicine Consent (please read in full)" I am agreeing that:

I have read this document carefully, read it in full, and understand the risk and benefits of a telemedicine consultation. I have had my questions regarding telemedicine explained and I hereby give my informed consent to participate in a telemedicine consultation. 

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