EnRoute Health

EnRoute Health Customer Service

Telephone: (866) 634-5377
Email: customerservice@enroutehealth.com
Website: EnrouteHealth.com

Telemedicine / Medication Refill Request Form

Contact Information:

Contact number with area code (exp: 2101234567)

Email:

Patient Information

First Name

Last Name

Date of Birth

If under 18, Name of Legal Guardian:

Must be present at time of Visit

What is your relationship to patient (Mother, Father)

Street Address

City:

State:

Zip Code

Apt#

Building #

Gate Code

Pharmacy Information:

Name of Pharmacy

Pharmacy number with area code

Must be a TEXAS Pharmacy

Reason for Consult

Give a brief description of your symptoms or reason for visit:

For Medication Refills please include name of medication, dose, frequency, and condition

Primary Medical Provider Information

Your Doctor's Name

Your Doctor's Contact number (2101231234)

Do you give EnRoute Health permission to send a copy of your visit to your primary medical provider?

Yes

I do not have a Primary Medical Provider

Medication Refill Policy:

All medication refill request require a video visit with an EnRoute Health Practitioner. There will only be a 30 day supply provided for most medications and less for some. Our intent is not to replace your primary medical provider. It is important that you continue to follow up with your doctor on a regular basis. Annual labs and a physical are important for your well being. If you are requesting monthly refills EnRoute Health will no longer provide refill services to you.

Consent for Treatment

By submitting, you acknowledge you have read, understand, and agree to the Terms of Service (see below). For children, a parent, or legal guardian, must be present at all times during a visit. Children under the age of 12 years do not qualify for TeleVisits and children under the age or 2 years do not qualify for MobileVisits. MobileVisit Consent for treatment will be obtained at time of visit. Please visit https://www.enroutehealth.com/legal for more information regarding our services.

Once you submit, please check your email to confirm your request was submitted correctly and for additional instructions.

Your information will be encrypted.

Terms of Service: This Consent to Use of Telehealth Services (“Telehealth Consent”) is incorporated into the EnRoute Health, LLC Terms of Service (the “Terms of Service”). In this Telehealth Consent, the terms “you” and “yours” refer to the person using the Service, or in the case of a use of the Service by or on behalf of a minor, “you” and “yours” refer to and include (i) the parent or legal guardian who provides consent to the use of the Service by such minor or uses the Service on behalf of such minor, and (ii) the minor for whom consent is being provided or on whose behalf the Service is being utilized. Capitalized terms used in this Telehealth Consent that have been previously defined in our Terms of Service will have the same meanings as provided in our Terms of Service. When using the Service, you will be consulting with your Provider(s) solely via the use of “telehealth”. Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, one or more of the following: Electronic transmission of medical records, photo images, personal health information or other data between a patient and a healthcare provider. Interactions between a patient and healthcare provider via audio, video and/or data communications. Use of output data from medical devices, sound and video files. The medical care and treatment provided to you by your Provider(s) through the Service will be provided via telehealth. The electronic systems used in the Service will incorporate network and so ware security protocols to protect the privacy and security of your information and will include measures to safeguard data to ensure its integrity against intentional or unintentional corruption. Anticipated Benefits The use of telehealth by your Provider(s) through the Service may have the following possible benefits: Making it easier and more efficient for you to access medical care and treatment for the conditions treated by such Provider(s) utilizing the Service. Allowing you to obtain medical care and treatment by Provider(s) at times that are convenient for you. Enabling you to interact with Provider(s) without the necessity of an in-office appointment. Possible Risks While the use of telehealth can provide potential benefits for you, there are also potential risks associated with the use of telehealth. These risks include, but may not be limited to the following: The information transmitted to your Provider(s) may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the Provider(s). The inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you. Your Provider(s) may not be able to provide medical treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services. Delays in medical evaluation/treatment could occur due to unavailability of your Provider(s) or deficiencies or failures of the technology or electronic equipment used. The electronic systems or other security protocols or safeguards used in the Service could fail, causing a breach of privacy of your medical or other information. Given regulatory requirements in certain jurisdictions, your Provider(s) diagnosis and/or treatment options, especially pertaining to certain prescriptions, may be limited. A lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors. Acceptance EnRoute Health is not a healthcare provider, and your Provider(s) will be solely responsible for any medical care and treatment provided or failed to be provided via the Service. All medical care and treatment you receive from your Provider(s) using the Service will be provided using telehealth. The delivery of healthcare services via telehealth is an evolving field and the use of telehealth in your medical care and treatment from Provider(s) may include uses of technology different from those described in this Telehealth Consent or not specifically described in this Telehealth Consent. No potential benefits from the use of telehealth or specific results can be guaranteed. Your condition may not be cured or improved and, in some cases, may get worse. There are limitations in the provision of medical care and treatment via telehealth and the Service and you may not be able to receive diagnosis and/or treatment through the Service for every condition for which you seek diagnosis and/or treatment. There are potential risks to the use of telehealth, including but not limited to the risks described in this Telehealth Consent. Your Provider(s) have discussed the use of telehealth and the Service with you, including the benefits and risks of such and you have provided oral consent to your Provider(s) for the use of telehealth and the Service. You have the right to withdraw your consent to the use of telehealth in the course of your care at any time, which you may exercise by providing written notice Enroutehealthllc@gmail.com. The withdrawal of such consent will prevent you from using the Service. Any withdrawal of your consent will be effective upon receipt of the written notice described above, except that such withdrawal will not have any effect on any action taken by EnRoute Health or your Provider(s) in reliance on this Telehealth Consent before it received your written notice of withdrawal. Nothing in this Telehealth Consent modifies any rights you may have to review or receive a copy of your medical records from your Provider(s), including any information included in such medical records that has been transmitted to your Provider(s) through the Service. You have read the Notice of Privacy Practices provided to you outside of the Service by your Provider(s) and you understand that your medical information is subject to all applicable laws regarding the confidentiality of such medical information. You have the right to access and amend your medical information as and to the extent permitted under applicable federal and state laws. You understand that the use of telehealth involves electronic communication of your personal medical information to Provider(s) who may be located in other areas, including outside of the state in which you reside. You understand that it is your duty to provide EnRoute Health and your Provider(s) truthful, accurate and complete information, including all relevant information regarding care that you may have received or may be receiving from other healthcare providers outside of the Service. You understand that it is your duty to provide EnRoute Health and your Provider(s) truthful, accurate and complete information, including all relevant information regarding care that you may have received or may be receiving from other healthcare providers outside of the Service. You understand that each of your Provider(s) may determine in his or sole discretion that your condition is not suitable for diagnosis and/or treatment using the Service, and that you may need to seek medical care and treatment a specialist or other healthcare provider, outside of the Service. You acknowledge that some photo graphic or other images you submit to the Service and that will be shared with Provider(s) may include portions of all of your breast or genitalia, and you hereby agree to the receipt of such images by your Provider(s) solely for the purposes of such Provider(s) providing you medical care and treatment via the Service. You understand that you are fully responsible for payment for all services provided by Provider(s) or through use of the Service and that you cannot use third-party insurance. You understand that you are fully responsible for payment for all services provided by Provider(s) or through use of the Service and that you cannot use third-party insurance. You represent that (a) you have read this Telehealth Consent carefully, (b) you understand the risks and benefits of the Service and the use of telehealth in the medical care and treatment provided to you by Provider(s) using the Service, and (c) you have the legal capacity and authority to provide this consent for yourself and/or the minor for which you are consenting under applicable federal and state laws, including laws relating to the age of majority and/or parental/guardian consent. You give your informed consent to the use of telehealth by Provider(s) using the Service under the terms described in the Terms of Service and this Telehealth Consent.

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