Agreement for New Patient COVID-19 Symptomatic Appointment

Our practice is a completely virtual establishment that provides telehealth services. Any information that is shared with us through the medical record form will only be used to provide care options for our patients. Any information shared with us will only be shared among staff, such as healthcare providers, nurses, and pharmacies for prescriptions. Any private or medical information will not be sold for any reason to external parties.

Information that will be shared among staff includes:

  • Patient medical records
  • Medical images
  • Live two-way audio and video calls
  • Output data from medical devices and sound and video files

All of our programs and electronic systems have strong security in order to protect you and your information. 

If in-person care is needed, patients are advised to contact their regular physician or go to the emergency room if they are experiencing an emergency. 

Potential benefits:

  • Fast, at-home care while being able to talk to a healthcare professional from the comfort of their own home
  • Efficient healthcare treatment options 
  • Discuss questions or concerns with healthcare professionals 

Possible Risks

We want to be transparent with all our patients, there are risks involved with any medical procedure. Even with telehealth appointments, we want all of our patients to be aware of these risks.

These risks may include:

  • Rarely, but not never, the health care provider may ask to reschedule the appointment in order to provide better quality care to the patient.
  • Delays can occur due to the failure of technology. In that situation, we will contact you to discuss how we will move forward with the consultation.
  • In very rare circumstances, there may be a breach of private, personal medical information.
  • Also in rare circumstances, incomplete or inaccurate medical information entered by the patient may result in poor judgment decisions on behalf of the health care provider.

These risks are only possibilities of what could happen and you have the option to not use our telehealth program to avoid these risks.

By signing up for our services, you understand and agree to the following:

  • I understand that any laws about privacy and protection also apply to telehealth communication. Personal and private information that I provide will not be sold for any databases or research outside of Starlight Wellness without written consent.
  • I understand that I can revoke my consent that allows the healthcare providers access to my personal information at any time if I no longer wish to be treated by them. I am responsible to communicate with Starlight Wellness that I want to revoke my consent. This will not affect any future treatment. 
  • I understand that there are different options for treatment and I have chosen telehealth. I understand that if I am experiencing an emergency, I am responsible to go to the nearest emergency room. 
  • I understand that my personal information may be shared through electronic communication with other healthcare providers within the organization. 
  • I understand that there are expected benefits and risks associated with taking part in telehealth practices. I understand that there are no guaranteed outcomes. 
  • I give my consent that my personal information may be shared with other professionals for billing and scheduling purposes. I also understand that there may be other individuals present at the time of my consultation, they will be addressed so I am aware of who is present. Any person(s) that will be involved in the care process will maintain confidentiality of any and all information. I understand that I have the right to omit information that may be personally sensitive or ask any nonmedical professional to leave the room at any point in time. 

By providing my information to the practice on the electronic medical form, I consent to all of the above. 

Other information:

  • Starlight Wellness practitioners are only licensed in Michigan. They can only treat patients that are also physically located in Michigan at the time of the consult.
    • Please note: The consultation fee does not include the prescription or any other medical equipment that is suggested as a treatment option for patients. 
  • We offer quick and convenient treatment options to patients. Telehealth is a great option for individuals that are looking for in-home treatment or may not have the time to physically go to a doctor’s office. This option is a great option for individuals looking for non-emergency situations, preventative, and early treatment of COVID-19. 
  • Our practitioners are extremely well-trained in their field and with several different treatment options. They are trained and have researched the different treatment options in order to provide their patients with the best option on a patient-to-patient basis. Our providers are available and ready to answer any questions that you may have about the different options for treatment. 
  • All of our healthcare providers are accredited as professionals in the healthcare field in order to provide the best possible care. In most situations, the call will occur over the phone but may be a video conference if needed. 
  • Healthcare providers will never prescribe any controlled substances (narcotics) as a treatment option.
  • The consultation fee will appear as pending until after the consultation has occurred. Payment collection at the start of the appointment process will serve as a placeholder. If the appointment is canceled after the payment information is received, there will be a refund of 75% of the consultation fee. The consultation fee does not include any prescription or medical equipment fees. 
  • You are more than welcome to discuss with your health insurance about reimbursement but we will not facilitate that on our part. 

Click the button below if you agree to the statements listed above and would like to learn more about our different appointment types.