I hereby attest that I have requested an online consult for me with a physician who is on the medical staff of Avon Medical Practice Limited (“Avon Medical”).
Via this consult, the Avon Medical physician will reach his or her conclusions regarding my medical diagnosis based solely on the information provided by me to Avon Medical.
To facilitate Avon Medical’s Physician’s online consult and for Avon Medical’s physician providing an opinion regarding my diagnosis, I authorize the release of any information pertaining to my health including medical history, pathology, laboratory and diagnostic results to Avon Medical’s physicians. Avon Medical is authorized, at its election, to obtain any of such records and information upon request.
However, I understand that there may be a charge for copying and handling my medical records and agree to be solely responsible for such charges.
In addition, I understand and agree that:
I hereby completely and irrevocably release Avon Medical their respective medical staff members, physicians and other health care professionals, insurance providers, administrators, officers, employees and directors (collectively, the “Avon Medical Parties”) of any and all errors and omissions, known or unknown, foreseen or unforeseen, knowingly or unknowingly, as well as all claims, actions or damages arising from or in connection with the online consult, conclusions or recommendations provided by Avon Medical physicians. Furthermore, I agree that Avon Medical Parties have no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission. As a condition to receiving the online consult service, I have read and acknowledge that I have given this consent of my own free will.
By accepting and agreeing to these terms, I acknowledge and agree to assume the risks of the limitations set forth herein.