Parent/Guardian Consent to Treatment via Telehealth

  1. I am the parent or legal guardian of someone under 18 years of age (“Minor”) seeking treatment via telehealth. The person being treated pursuant to this Consent to Treatment via Telehealth is referred to as the “Patient”.
  2. I understand that Curology, Inc.’s affiliated healthcare providers (“healthcare provider”) treat patients via telehealth, and I wish for the Minor to be treated via telehealth. I understand that the telehealth treatment may involve all of the following (collectively “telehealth visit”):
    • Electronic creation and transmission of medical records, photo images, personal health information, or other data between me and or the Minor as the Patient and healthcare providers and among healthcare providers and entities; and
    • Interactions between me and or the Minor as the Patient and a healthcare provider via data communications (including store and forward technology); and
  3. I understand there are potential risks to a telehealth visit, including interruptions, unauthorized access which could disclose health information, and technical difficulties. I understand that I, the healthcare provider or the Patient can discontinue the treatment via telehealth visit if it is felt that the situation warrants.
  4. I understand that Patient information as part of the telehealth visit may be shared with other individuals or entities for technological and billing purposes and any information collected by a healthcare provider as part of this telehealth visit will be used for analyzing the patient’s health, possible treatments, to conduct follow-up activities with the Patient, including to offer other Curology products and services to the Patient, and will be used further as stated in the Curology Privacy Policy.
  5. I understand that Patient care at Curology is limited to the diagnosis and treatment of acne and skin aging and related disorders and not for the diagnosis or treatment of any other medical or dermatological conditions, including skin cancer. I understand that the Website is not a substitute for the in-person treatment or advice of the Patient’s local dermatologist, primary care physician, or any other qualified healthcare professional. I understand that the Patient should never delay seeking advice from the Patient’s local dermatologist, primary care physician, or any other health professionals if advised to do so by the Patient’s Curology healthcare provider, or if the Patient has any concerns.
  6. I understand that Curology undertakes no obligation to review the inactive ingredients and or the base ingredients in any product that is recommended or sold to the Patient, including, without limitation, to ascertain that Patient is not allergic to such inactive or base ingredients. I further understand that it is solely the Patient’s (or the Patient’s legal guardian’s) responsibility to review those ingredients, as listed on the Curology website.
  7. I understand that if the Patient has an emergency health issue of any nature, the Patient (or the Patient’s legal guardian) should call local emergency medical number or take such other action as necessary.
  8. I understand that I have the right to request that the Medical Record established with Curology be sent to my primary healthcare provider. I may request this on my dashboard.

By continuing, I represent:

  • That I have read or had this form read and/or had this form explained to me.
  • That I fully understand its contents, including the risks and benefits of the telehealth service provided through Curology’s affiliates.