By the use of Parasol Virtual Dermatology Services via the VSEE app or online platform, I hereby request,
consent and authorize VSee, Parasol Virtual Dermatology, and their subsidiaries, affiliates,
representatives, and agents (collectively, “VSee” and “Parasol Virtual Dermatology”) and their employed
or contracted physicians, physician assistants, nurse practitioners or other licensed health care
professionals in its care network (the “Practitioners”), to utilize telemedicine through VSee’s proprietary
systems, methods and protocols to access, diagnose, consult, treat and educate me and those I am
authorized to represent (the “Services”).
I acknowledge and consent to see a Practitioner via telemedicine. I understand that my eligibility to
receive a visit via telemedicine is based on the Practitioner’s medical judgment that it is appropriate and
that the quality of care will not be diminished by the use of telemedicine. I understand that a
telemedicine visit is distinct from an in-person visit because I will not be in the same room as the health
care Practitioner, and instead, I will communicate with the Practitioner through advanced
communication technology using live video and audio feed.
I acknowledge that in order to protect my privacy, I need to choose a private location to place my
telemedicine call. I understand that in order to provide the best call environment, I should reduce
background light from windows or light emanating from behind me. I understand that my camera
should be placed on a secure, stable platform to avoid wobbling and shaking during the telemedicine
session. To the extent possible, my camera should be placed at the same elevation as my eyes with my
face clearly visible to the other person. I understand that I will be informed of the presence of any third
party, including those that may be present to assist with the audio or video equipment, and that I have
the right to: (1) omit specific details of medical history or physical examination that are sensitive to me
during such third party presence, (2) ask non-medical personnel to leave the telemedicine examination
room, and/or (3) terminate the consultation at any time by notifying the Practitioner or disconnecting
from the telemedicine portal.
I understand the potential risks of receiving the Services via telemedicine include: delays in medical
evaluation due to technological equipment failure, a lack of access to all relevant information, or a
security breach allowing unauthorized access to my confidential medical information. I understand that
my Practitioner or I may terminate the telemedicine visit at any time, including if the Practitioner or I
feel that an in-person visit is necessary for any reason. I have had the Services and alternatives to
telemedicine for my Services explained to me and I choose to and continue with a telemedicine visit.
I understand that any complaint may be filed with the Secretary of the Department of Health and
I have read and understood the written information provided above. I agree that the information
provided above adequately explains the Services, along with the risks and benefits to me of said
Services. I have had the opportunity to ask questions about this information – if I had any questions, all
of my questions have been answered in full. By electronically signing this form, I acknowledge and agree
to all of the above, and certify that I have no questions and/or have had my questions answered in full.
By electronically signing this informed consent before the consult, and being made aware via Parasol
Virtual Website online disclosures, I am agreeing to conduct transactions electronically, and intend for
my electronic signature to be a binding electronic signature on myself and those I am authorized to
represent. Further, I understand and acknowledge that I am digitally receiving a copy of this Agreement
concurrently upon execution to print and/or retain a copy of this Agreement, and may also request a
paper copy from VSee using the contact information below:
If you have any questions, please email email@example.com or for technological questions and
concerns contact firstname.lastname@example.org.