Ankr platform enables your medical team to deliver prompt, high-quality care to you using telemedicine (also called telehealth) services such as interactive videoconferencing equipment and phone equipment. Ankr Health’s technology and its employees merely facilitate these services between you and your healthcare provider. We do not provide any medical advice, opinion, diagnosis, or treatment for any health/medical conditions. Your participation in a telemedicine service through the Ankr platform constitutes an agreement with the following in addition to our platform’s general terms and conditions and privacy policy:

1. I consent to receiving calls and messages (SMS and MMS) from Ankr Health.
2. I consent to receiving emails from Ankr Health.
3. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.  
4. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room. 
5. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
   • If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit. 
6. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
   • I may revoke my right at any time by contacting Ankr Health by phone, email, or through the website as appropriate.
7. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
8. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
   1. I understand that my insurance carrier will have access to my medical records for quality review/audit. 
   1. I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telemedicine visit.
   • I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits. 
9. I understand that this document will become a part of my medical record.   

By signing this form, or receiving any telemedicine services through the Ankr platform, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state as stated while consenting for my telemedicine visit(s).

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Patient/Parent/Guardian Printed Name       Patient/Parent/Guardian Signature 

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Witness Signature (Optional)                         Date