INFORMED CONSENT

KEEPS HAIR RESTORATION

Effective: January 7, 2022

Last Updated: January 7, 2022

Consent For In-Person Treatment, Including Hair Transplant Services

The following consents apply to users who are opting for in-person services at Hudson NYC Medical, P.C. (the “Practice”), including hair transplant services:

Following an in-person evaluation, potential hair transplant or other procedures will be explained to me, including Risks, Benefits, and Alternatives, and I will have an opportunity to have all of my questions answered before being asked to provide final consent to any procedure.

I understand that results are not guaranteed and that complications may occur with any treatment.  Prior to my procedure, I will be provided a medical fact sheet and consent form regarding this information.

In-person consultation. Every patient who has any surgical procedure with a clinician at the Practice (a “Clinician”) undergoes a consultation with the Clinician. A preliminary orientation (before your consultation with the Clinician) is often conducted by trained staff who may only disseminate general information about hair restoration procedures. Since they are not Clinicians, such staff are prohibited by law from diagnosing, treating, operating for, or prescribing for any physical condition.

Payment Methods. I understand and agree that I’ll be required to pay a $1,000 USD non-refundable deposit towards the total cost of the treatment plan in order to schedule a date for the procedure. I also understand and agree that the remaining balance of the total payment for services shall be made prior to the time of service. I understand that the Practice does not accept insurance of any kind. I will be prepared to pay in full at least 24 hours prior to the time of service, with either cash, credit/debit card, or through a financing option provided by the Practice such as Affirm, if approved.

Cancellation Policy. I understand that my appointment must be canceled at least twenty-four (24) hours in advance or I will be responsible for full payment for the missed visit. In addition, if I am more than fifteen (15) minutes late to my appointment, Practice may have to reschedule the appointment to a different day or time. Late rescheduling will also be subject to a fee of $3,000 USD. Practice requires all clients to have a credit card on file after their first visit. Any late cancellation fees incurred will automatically be charged to your credit card on file.

Practice Communication. By signing this agreement, I consent to receive text messages or emails from Practice and/or its agents on my cell phone or other devices. I understand that text messages and emails sent by Practice may include appointment reminders, changes in previously scheduled appointments, or may provide advice or education. I further acknowledge and agree that:

• I authorize Practice to send text messages to the cell phone number I have provided to create my account. Should I wish to update this phone number, I will need to update my cell phone number with the Practice through my Keeps online account.
• I authorize Practice to send emails to the email address I have provided to create my account. I understand that if I wish to change this address, I must update my email address through my Keeps online account.
• While Practice does not charge for this service, standard text messaging rates may apply as provided in my wireless plan. I have been advised that I may contact my carrier for pricing plans and details.
• I may revoke my request for further communications via text or email at any time by notifying Practice in writing. However, if I continue to communicate with Practice via text or email, Practice shall assume that my consent remains valid.
• Because emails sent over the Internet or texts sent over the control channel without encryption are not secure, I understand the risks associated with email and text messaging, including without limitation: that emails and text messages could be intercepted by unknown third parties; email content can be changed without the knowledge of the sender or receiver; backup copies of emails may still exist even after the sender and receiver have deleted the messages; and emails can contain harmful viruses and other programs.
• Practice has recommended that I delete all text messages or emails as soon as possible after reviewing them to limit any unauthorized exposure.

I consent to the taking of photographs as part of the medical record.

I understand that I will not be able to operate a motor vehicle while under the influence of medication.

Consent for Telehealth Services

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by Hudson NYC Medical, P.C., KMG Medical Group MO, P.C. and its affiliated entities KMG Medical Group P.A. and its related practices, including Michael Karagas, M.D., P.C. (collectively “KMG”), may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

KMG physicians (our “Providers”) are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

Expected Benefits:

• Improved access to care by enabling you to remain in your home while the KMG provider consults and obtains test results at distant/other sites.
• More efficient care evaluation and management.
• Obtaining expertise of a specialist as appropriate.

Possible Risks:

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
• In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
• In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact (551) 290-3248 or help@keeps.com.

By checking the box associated with “Informed Consent,” you acknowledge that you understand and agree with the following:

1. I hereby consent to receiving KMG’s services via telehealth technologies. I understand that KMG and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the KMG provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
2. I have been given an opportunity to select a provider from KMG prior to the consult, including a review of the provider’s credentials.
3. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that KMG will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
4. I understand there is a risk of technical failures during the telehealth encounter beyond the control of KMG. I agree to hold harmless KMG for delays in evaluation or for information lost due to such technical failures.
5. I understand that 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. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the KMG providers are not able to connect me directly to any local emergency services.
6. I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the KMG provider (e.g. labs or bloodwork). I also understand that if I seek in-person treatment for hair transplant or other services, I will review and will be asked to accept additional consent terms.
7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
8. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the KMG provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
9. I understand that there is no guarantee that I will be given a prescription at all.
10. I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.

Additional State-Specific Consents:

The following consents apply to users accessing the KMG website for the purposes of participating in a telehealth consultation as required by the states listed below:

Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (AK Stat. 08.64.364).

Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12- 2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (A.R.S. § 36-3602).

Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (C.G.S.A. § 19a-906).

D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (17 DCMR § 4618.10).

Kentucky: If I am a Medicaid recipient, I recognize I have the option to refuse the telehealth consultation at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a Medicaid benefit to which I am entitled. I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I also understand that I have the right to object to the videotaping of the telehealth consultation. (KY Admin. Regs. Tit. 907, 3:170).

Louisiana: I understand the role of other health care providers that may be present during the consultation other than the KMG provider. (46 La. Admin. Code Pt XLV, § 7511).

Maryland: Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Code of MD Reg. 10.41.06.04).

Nebraska: If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (NE Revised Stat. 71-8505; NE Admin. Code Tit. 471, Ch. 1).

New Hampshire: I understand that the KMG provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (NJ Rev. Stat. § 45:1-62).

Pennsylvania: I understand that I may be asked to confirm my consent to behavioral health or tele-psych services.

Rhode Island: If I use e-mail or text-based technology to communicate with my KMG provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the KMG provider terminating the e-mail relationship. (Rhode Island Medical Board Guidelines).

South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code 1976 § 40-47-37).

Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient.

Texas: I understand that my medical records may be sent to my primary care physician. (V.T.C.A., Occupations Code § 111.005).

Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving tele-dermatology or tele-ophthalmology services via KMG does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (VT Stat. Ann. § 9361).

Note, these state-specific telehealth consent rules are constantly changing and being updated/revised. One approach is to have us update this form periodically to revise for new state specific changes. Another approach is to eliminate this state-specific section and just use an informed consent which substantially complies with the spirit and purpose of the rules, albeit might not meet each state’s specific language.

Patient Consent

I have read this document carefully, and understand the risks and benefits of my in-person visit and any telehealth consultations and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in the in-person visit and any telehealth consultations under the terms described herein.

By clicking the box below and by signing this form during my in-person visit, I agree that I have read and understand this Informed Consent. I also agree and acknowledge that:

1. I have read this document carefully, and understand the risks and benefits of the proposed treatment and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in treatment under the terms described herein.
2. I understand that my electronic or in-person signature on this form indicates that I have read and understand the preceding information regarding my treatment. I understand that if I have any questions about this information I should ask my physician.
3. I hereby state that I have read, understood, and agree to the terms of this document, including the Services to be provided by Practice, permitted payment methods and Practice’s cancellation policy. I have had an opportunity to ask questions, and have had my questions answered to my satisfaction. I also understand that, under HIPAA, I have certain rights to privacy regarding my health information. I have received, read and understand Practice’s Notice of Privacy Practices which contain a complete description of the uses and disclosures of my health information. I understand that Practice has the right to change its Notice of Privacy Practices from time to time and that I may contact Practice at any time to obtain a current copy of the Notice of Private Practices.

For In-Office Use

Patient Signature: _______________________________________

Print Name: ________________________________________

Date: ________________________________________