Virtual House Call Waitlist

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank for your interest in our House Call service. We are BETA testing this concept because we believe that we can improve stress levels and provide peace of mind to our community by providing a pathway that addresses a few common health conditions that just needs a brief evaluation.

Please complete this form and we will reach out to you within 36 hours to provide you with some appointment options.

Email *

First and Last Name *

Phone Number *

Please list 2-3 timeframes that you are available for an appointment. We will do our best to match your preferences.

Do you consent to receiving a text message for faster notification of an appointment availability?

Yes

Clear selection

What condition are you seeking treatment for?

Sinus symptoms

Skin symptoms

Gout symptoms

Urinary symptoms

Vaginal bacteria symptoms

Vaginal yeast symptoms

Clear selection

Informed Consent For Telehealth Services

By signing the end of this document, you acknowledge that you understand and agree with the following:

1. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Inspired Wellness will take steps to make sure that my health information is not seen by anyone who should not see it.

2. I understand there could be risks related to the privacy and security of your internet or phone connection. Other risks might be equipment failure, poor video connection or visual quality. The video visit is encrypted for security and not recorded.

3. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.

4. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the Inspired Wellness staff are not able to connect me directly to any local emergency services.

5. I understand that if I participate in a consultation, that I have the right to request a copy of my medical record which will be provided to me at reasonable cost of preparation, shipping and delivery.

6. I understand I need to log into the telehealth link to ensure I have downloaded and am able to open Zoom on my computer or mobile device. I understand once I open the visit, if I receive a response that the provider is in another meeting, I will keep the video link open and wait for the provider to arrive.

7. I understand to call/text the clinic at (360) 320-1798 in the event I am experiencing any technical difficulties or other issues preventing me from attending my scheduled video appointment.

8. I understand I am responsible for using this technology in a secure and private location so that others cannot hear my conversation. I understand that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.

9. I understand Carina Hopen, MD is a licensed physician in the state of Washington and cannot provide services to anyone residing outside of Washington state.

10. I understand it is my responsibility to report to my primary care provider or the emergency room my symptoms worsen requiring urgent or emergency attention.

I have read this document carefully, and I understand the risks and benefits of the telehealth consultation.

Initial Here:

I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.

Initial Here:

I understand that Dr. Hopen treats individuals between the ages of 18 and 65. I affirm that I am between 18 and 65 years old. (Please do not schedule a visit if you are not within this age range.)

Initial Here:

I understand that Dr. Hopen will only address the single condition for which I have scheduled the visit for. I reviewed the criteria for the appointment, and I meet the criteria.

Initial Here:

I understand my prepaid appointment fee does not include the cost of medications (if prescribed).

Initial Here:

I understand I will forfeit my payment if I attempt to schedule an appointment with the intent of discussing a condition other than the one identified in the appointment confirmation. (Please be respectful, honest, and stick to your selected condition).

Initial Here:

I agree to provide my date of birth (DOB) which will be used to activate my Charm Electronic Health Record account. I understand I will receive a separate email regarding my account activation.

My DOB is:

After we have identified an appointment day and time, you will receive an email containing a link to prepay for your video visit. Once your payment is received, you will receive an email confirmation of your appointment. Please review the email carefully as it will contain the Zoom link to connect with the physician.

Thank you!

Be well and stay inspired!

Inspired Wellness, PLLC

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Inspired Wellness, PLLC. Report Abuse

Forms