In connection with accessing the Medical Services and Telehealth Visits, you acknowledge, understand, consent and agree to the following:

1. Telehealth Visits involve the use of electronic communications to enable the Providers at different locations to share individual patient medical information for the purpose of providing the Medical Services and improving patient care.
2. A Telehealth Visit is not the same as an in-person direct patient/healthcare provider visit, because you will not be in the same room as the Provider providing the Medical Services.
3. You understand that parts of your care and treatment that require physical tests or examinations may be conducted by providers other than the Provider.
4. The communications systems used during the Telehealth Visits will incorporate reasonable security protocols to protect the confidentiality of patient information and will include reasonable measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
5. Nevertheless, you understand that there are potential risks to the use of this technology during the Telehealth Visits, including but not limited to:
   
   a. Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or network interruption;
   
   
   b. Security protocols could fail, causing a breach of privacy of personal health information;
   
   
   c. Lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other negative outcomes; and
   
   
   d. Interruptions, unauthorized access by third parties, and technical difficulties.
   
   
6. You are aware that either the Provider or you can discontinue the Telehealth Visit if either believes that the videoconferencing connections are not adequate for the situation.
7. You understand that the Telehealth Visit will not be audio or video recorded at any time, and you agree not to audio or video record the Telehealth Visit.
8. You agree that the Professional Entities may use and disclose your Protected Health Information (as defined under HIPAA) in accordance with applicable law and the Notice of Privacy Practices provided to you.
9. You acknowledge that you have the right to request termination of the Medical Services at any time.
10. You agree that you are entering into an agreement with the Professional Entities which shall be a provider of the Medical Services to you, which means, among other things, you are entering into a practitioner-patient relationship with the Provider associated with the Professional Entities that personally performs the Medical Services.
11. You understand and agree that KBS, Inc. is the provider of certain administrative services to the Professional Entities and does not provide professional medical services itself.
12. In connection with the Medical Services and the provision of Telehealth Visits, you consent and agree to the release of your medical records which other treating providers may have.
13. If you are prescribed medications by the Provider, you must be seen at least once every three months, if not more frequently, as directed by the Provider. The Provider cannot refill prescriptions without an appointment within the timeframe specified.
14. You will tell the Provider about all medications you are taking, especially narcotic pain relievers or barbiturates.
15. You understand that, if your clinical condition is determined to be severe, you may be prescribed medications only if you are engaging in a certain level of care, which may include seeing a licensed psychotherapist and/or participating in a substance treatment program.
16. You understand that, if telehealth is not appropriate for you, the Provider reserves the right to refer you to other care providers.
17. You understand that, in an emergency, you should dial 911 or go to an emergency department.
18. You understand that 24-hour help is available through the Suicide and Crisis Lifeline by calling or texting 988.

You have read and understand the information provided above, and understand the risks and benefits of telemedicine, and by accepting these TOS and the Terms and Conditions, you hereby give your informed consent to participate in a Telehealth Visit under the terms described herein.

Research

You consent to your de-identified data being used for research purposes, as we periodically participate in clinical and scientific research to improve mental health treatment.

Additional State-Specific Consents

The following consents apply to patients participating in a telehealth consultation as required by the states listed below:

Texas:

I have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS
Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.  

Iowa: 

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

With respect to Telehealth Visits, a feature of the Medical Services provided by the Professional Entities is that the Provider may prescribe to you the use of psychotropic medications and/or ketamine independently  or in connection with mental health therapy and treatment.  It is solely within the Provider’s own professional medical judgment whether prescribing you psychotropic medications and/or ketamine is medically appropriate. Initiation of a Telehealth Visit DOES NOT GUARANTEE you will be prescribed psychotropic medications and/or ketamine.

The Professional Entities do not endorse any specific medication, pharmacy, or pharmacologic product. There is no guarantee a prescription will be written by using the Medical Services. If a Provider prescribes a medication such as ketamine, the Provider will limit supply based upon applicable regulations and will only prescribe a medication as determined in the Provider’s own discretion and professional judgment. Providers may also deny care for actual or suspected misuse of the Medical Services for prescriptions.

I understand that medication prescribed to me may have risks of adverse events and/or side effects. I agree to provide true and complete information to my Provider in order for them to make a determination as to whether I’m a good candidate for ongoing treatment or a particular psychotropic medication. I recognize that providing untrue or incomplete information may put me at greater risk of adverse events and/or side effects. I understand that adverse events and/or side effects can be caused by a number of factors, including other health conditions, allergic reactions, side effects, or interactions between other medications or supplements that I am taking. I understand that it is my responsibility to make my Provider immediately aware of any updates or changes to my health status, or any medications or supplements that I am taking or have recently taken.

I understand that adverse events from taking psychotropic medication include but aren’t limited to increased risk of suicide, serotonin syndrome, gastrointestinal bleeding, mania, birth defects, angle-closure glaucoma, seizures, hyponatremia, and heart, liver, or kidney issues.

• Ketamine is approved by the U.S. Food and Drug Administration (“FDA”) for anesthesia and for sedation during medical procedures. 
  
• The use of Ketamine for the treatment of depression, anxiety, post-traumatic stress disorder (“PTSD”), obsessive compulsive disorder (“OCD”), or drug or alcohol abuse HAS NOT BEEN EVALUATED AND APPROVED BY THE FDA. When Ketamine is used for these “off-label” purposes listed, Ketamine is typically not the first line therapy and must be carefully considered as compared to other conventional therapies and medications, including, without limitation, selective serotonin reuptake inhibitors (“SSRIs”) and cognitive behavioral therapy.
  
• Risks of ketamine vary depending on the dose of the oral ketamine. In addition, the duration and intensity of its effects can vary highly from person to person. Below is a non-exhaustive list of common, uncommon, and rare side effects, which is not intended to be a comprehensive list of all possible side effects.
  
• Out of body experience; 
• Hallucinations; 
• Vivid dreams and nightmares; 
• Change in motor skills; 
• Nausea and vomiting; 
• Dizziness;
• Blurred vision; 
• Increased saliva production; 
• Increased heart rate and blood pressure;
• RISK OF FALLS IF WALKING UNASSISTED.
• Rash; 
• Double vision; 
• Increased pressure in the eye; 
• Jerky arm movements; 
• Cognitive issues, including memory problems and 
• Verbal processing.
• Cystitis;
• Uropathy;
• Cravings for ketamine;
• Dependency on ketamine;
• Abuse or misuse of ketamine.
  
  

EVEN MORE SEVERE SIDE EFFECTS, UP TO AND INCLUDING DEATH, ARE POSSIBLE BUT EXTREMELY RARE, SUCH AS IN THE EVENT OF A FATAL ALLERGIC REACTION TO THE MEDICATIONS.

Emotional Disturbance

Patients may experience a state of severe agitation, confusion, or become combative, which may cause threat of severe harm or bodily injury to both themselves and those around them. The risk of such a reaction to the Medical Services and the prescription may be reduced by avoiding loud noises and disturbing external stimuli. 

In addition, ketamine can cause various emotional and psychological conditions, including but not limited to flashbacks, hallucinations, feelings of unhappiness, restlessness, anxiety, insomnia and disorientation.

Dosing Error and Drug Interactions and Other Risks

Dosing errors or other unknown drug interaction may require emergent medical intervention or hospitalization. In addition, there exists a risk of other medications interacting with ketamine. 

You must abstain from any or all illicit substances for a minimum of 6 weeks prior to your ketamine treatment. Additionally, not adhering to the prescribed dosing may result in injury, illness or death.

SEVERE MEDICATION INTERACTIONS ARE POSSIBLE SO PLEASE TELL THE PROVIDER ALL OF THE MEDICATIONS, SUPPLEMENTS AND SUBSTANCES YOU ARE TAKING OR HAVE RECENTLY TAKEN.

It is possible that ketamine may not help your depression, anxiety, PTSD, OCD, or drug or alcohol abuse.

Upon receipt of your prescribed ketamine product, if medically appropriate, you must secure a safe place to store the product out of reach of anyone other than you, the patient for whom it was prescribed.

As part of the Medical Services, you agree to abide by the following rules and safety precautions:

It is essential that you be followed very closely during and after your treatment. This may include blood pressure and pulse measurements, psychological measures before and after each session, and ensuring the availability of an identified support person (sitter).

You agree to remain at a predetermined, safe location with your trusted support person (sitter) available throughout the duration of your ketamine experiences, for at least two hours and until your support person is comfortable that you are safe and ready to be on your own.

You will not eat or drink for at least four hours before any ketamine lozenge (oral) session. You will take all of your usual  morning medications with a few sips of water before a ketamine lozenge session, EXCEPT for Lamictal, any benzodiazepines, any stimulants, and any sedating drugs including narcotic pain medication.

You will NOT drive a car, operate hazardous equipment, or engage in hazardous activities during Treatment Duration, and for 24 hours after each treatment, as reflexes may be slow or impaired.

You will NOT attempt to walk without the support of a sitter, especially to the bathroom, during the Treatment Duration due to the risk of fall and subsequent bodily injury as you may have impaired balance and motor coordination.

You will NOT conduct business or make any important decisions during the Treatment Duration and the remainder of the day after the Treatment Duration.

You will NOT engage in any sexual activity during Treatment Duration.

You will refrain from alcohol or other substances prior to the treatment and for 24 hours after the Treatment Duration.

You will tell the Provider about all medications you are taking, especially narcotic pain relievers or barbiturates.

If you experience an unexpected or troublesome side effect, you will contact the Provider using your care team portal. If you cannot reach the Provider promptly, you will call your primary care doctor or call 911. If you experience a life-threatening emergency, you will call 911 to seek emergency treatment.

KETAMINE THERAPY ALONE IS NOT A COMPREHENSIVE TREATMENT FOR DEPRESSION, ANXIETY OR ANY PSYCHIATRIC DISEASE, CONDITION, OR SYMPTOM. Ketamine treatment is meant to augment (add on to, not be used in place of) a comprehensive treatment plan. 

For best results, you are advised to continue , or begin, weekly or biweekly individual or group psychotherapy while receiving ketamine treatments, and for the duration of your psychiatric symptoms. In addition, it is recommended that you continue treatment with your mental health professionals from whom you regularly seek care, such as an existing therapist, psychologist, or psychiatrist.

Suicidal Ideation

Psychiatric illnesses (especially, depression) and addictions carry the risk of suicidal ideation (thoughts of ending one’s life). If you experience suicidal ideation, and if you cannot obtain immediate treatment from a mental health professional, you should seek prompt emergency medical treatment by calling 911 or visiting a local emergency department.

Pregnancy

KETAMINE USE DURING PREGNANCY IS NOT RECOMMENDED

Other psychotropic medications may not be safe for use during pregnancy, so it’s essential for you to alert the Provider if you become pregnant or plan to become pregnant during your treatment.

Changes to this Agreement

When we make changes, we will revise the “last modified” date at the bottom of this document. We encourage you to review these TOS periodically. Your continued use of Telehealth Visits constitutes your agreement to the changed TOS.

Effective Date: March 29, 2024

Previous Telehealth and Informed Consent (effective through July 27th, 2023) available here.