Consent and Agreement: 

By submitting this form, I acknowledge that I have read and understood Aury Health’s client services agreement, telehealth consent, HIPAA and privacy policies, financial agreements, and disclaimers listed on the website. I understand that the questionnaires are not a substitute for an in- person consultation with a healthcare provider and that treatment decisions are based on the information that I provide to Aury Health providers.

I also understand and agree to the following:

The limitations and benefits of a remote consultation.

The potential for technological issues that may affect the quality of the consultation.

The use of photographs and personal health information for diagnosis and treatment.

The need for further in-person evaluation or referral, if necessary.

The responsibility to provide accurate and truthful information to the best of my knowledge.

I hereby authorize Aury Health, Inc to provide treatment recommendations as necessary or advisable in the treatment of my condition.

I hereby authorize and assign Aury Health, Inc all the payments for medical and prescription services rendered. I understand that I am financially responsible for all charges.

Telederm HIPAA Release Form

I hereby authorize Aury Health, LLC to disclose my protected health information (PHI) as stated in the HIPAA policy and Privacy Policies for payment processing, fulfilling prescriptions, image storage, and accessing encrypted patient portals related to my dermatological services:

I understand that the information to be disclosed may include, but is not limited to:

Medical records

Diagnostic reports

Treatment plans

Prescription details

Recipient Information

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA) and all subsequent revisions, I have the right to privacy regarding my protected health information. I understand that this information will be used to carry out treatment, payment, and health care operations.

Duration of Authorization:

This authorization shall remain valid for the duration of my treatment with Aury Health, LLC, unless revoked by me in writing.

Revocation of Authorization:

I understand that I have the right to revoke this authorization at any time by submitting a written request to Aury Health, LLC at [email protected]

I understand that revoking this authorization will not affect any actions taken by Aury Health, LLC prior to the revocation.