ACCURATE MD AGREEMENT TO PROCEDURES, PRACTICES, TREATMENT AND/OR CLAIMS

By checking the box below, I hereby expressly understand and agree to the following:

Accurate MD Procedures and Practices

• I acknowledge that I am paying Accurate MD solely to schedule a consultation with an Accurate MD referral doctor. Accurate MD is not a doctor and does not provide medical advice or medical treatment of any kind. Only the doctor to whom I may be referred by Accurate MD may prescribe one or more medications or refills, as the doctor may deem necessary or appropriate in his/her sole discretion. Regardless of (i) the quantity or type of medicine prescribed; or (ii) the number of refills the doctor prescribes or the pharmacy fills, I agree to pay Accurate MD the full consultation price for such referra
  
  
• Accurate MD reserves the right to refuse service to any person it deems necessary or appropriate in its sole discretion.
  
  
• I acknowledge that Accurate MD will excuse one (1) missed consultation and will not charge me the consultation referral fee. Any further misses will result in a $150 administrative charge in addition to the full charge of the appointment. Patients absent from our system for 6 or more months will require a new “in person “ exam
  
  
• I acknowledge that Accurate MD solely offers referral services for telephonic physician/patient consultations and does not provide medical services of any kind. Only the doctor to whom I may be referred can provide medical advice.
  
  
• I acknowledge that Accurate MD does not assume any liability for services provided by the physician(s) to whom I may be referred, the pharmacies where my prescriptions may be filled nor does Accurate MD assume any liability for the products or information featured on this website
  
  
• I acknowledge that Accurate MD does not offer refunds for medication(s)
  
  

Patient's Responsibilities, Acknowledgements and Certifications

• I certify that the medical records that I provide to Accurate MD are current, true, correct, and factual and have been obtained from my current primary care physician (“PCP”) and have not been altered in any way. I further certify that the identification that I provide to Accurate MD as proof of my identity is factual and has not been altered in any manner.
  
  
• I understand and expressly agree that in order to receive treatment from any doctor to whom I may be referred by Accurate MD. I must see that doctor, for the first meeting or conference in person, at least once per year, in person, with the possibility of further ”in person” visits ordered solely at the discretion of the doctor to whom I was referred. (I understand medical records are not mandatory for this option.) I hereby expressly consent to the above conditions and agree that if said conditions are not met that I shall not be entitled to any medical consultation by an Accurate MD referral doctor via the internet, over the phone, or otherwise
  
  
• I acknowledge that treatment and prescription medication(s) may cause side effects. It is the physicians’ obligation (and NOT Accurate MD’s) to advise me of any such possible side effects. I understand that it is my responsibility to communicate to the physician, both through verbal conversations and in written form, my full and complete medical history in order for the physician to properly treat my condition. Furthermore, it is my responsibility to ensure that the physician is in contact with my PCP to ensure proper treatment and joint evaluation.
  
  
• I further acknowledge that if I suffer adverse conditions, side effects or any other problems with my treatment or medication(s) I must immediately (depending on the seriousness of the problem) notify my local emergency room and or my PCP and the physician to whom I was referred by Accurate MD.
  
  
• I agree to defend, indemnify, and hold harmless Accurate MD and its affiliates, and their respective directors, officers, members, employees, agents, successors and assigns from and against any and all actions, judgments, claims, losses, damages, expenses or costs (including attorneys’ fees and costs and expenses of defense) and liabilities which arise out of, relate to or are in any way connected with any services rendered on my behalf.
  
  
• I certify that I am at least 21 years of age and that I have answered all questions honestly, accurately and to the best of my knowledge. Furthermore, I certify that I am capable of making my own decisions and am in no way impaired from doing so based on my medical condition(s).
  
  
• I certify that my medical condition(s) is a real, legitimate medical condition(s) and that I have a need for treatment.
  
  
• I agree to furnish all available, updated, medical records to the doctor referred to me by Accurate MD as that doctor deems necessary or appropriate. I also give my express permission allowing my PCP to discuss such records and any other pertinent information as deemed necessary, with the doctor to whom I may be referred.
  
  
• I agree to keep my patient ID number and password confidential and not allow others to access my account.
  
  
• By checking the box I acknowledge that I have read, understand and agree to the preceding terms and conditions