Tele-Wellness and App Communication Agreement and Consent
 
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Email *
Preferred Name *
Full Legal Name *
Date of birth (you must be 18 years of age) *
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Phone Number *
Setting up google Chat
You must follow ALL steps before we can send you messages
1.  Download Google Chat on your phone
2. Log in to google chat with the email that you have provided us, then exit the app
3. Visit your phone's settings > scroll down to chat settings > select notifications > under show previews, select NEVER
4. Visit chat.google.com - make sure that you are signed into the same email account that we have
 THEN > click on the gear icon > under email notifications: Select OFF  (the default setting says Only @mentions & direct messages)

Google Chat - I understand and have followed all of the directions above.  I will contact HRI with any questions.  All of my settings are correct as listed above. *
HRI - Electronic Communications and Virtual Appointment Portal
"The practice" refers to Holistic RI (HRI), and HRI independent contractors including but not limited to all practitioners and affiliates.  

The Practice uses reasonable efforts to maintain the Patient Portal, but the Practice is not responsible for any defects or
failures associated with the Patient Portal, any part thereof or any damages (such as lost profits or other consequential
damages) that may result from any such defects or failures. The Patient Portal may be inaccessible or inoperable for any
reason, including, without limitation: (a) equipment malfunctions, (b) periodic maintenance procedures or repairs which
the Practice may undertake from time to time or (c) causes beyond the control of the Practice or which are not foreseeable
by the Practice. In addition, the Practice makes no guarantees as to the web sites and information located worldwide
throughout the Internet that you may access as a result of your use of the Patient Portal, including as to the accuracy,
content, or quality of any such sites and information or the privacy practices of any such site. The Practice is not a backup
service for storing data you submit to the Patient Portal, and the Practice shall have no liability regarding any loss of such
data. You are solely responsible for creating backups of any data you submit using the Patient Portal.

The Patient Portal is a secure website that allows you to use a computer to interact with medical information via the
internet. The Patient Portal also allows you to communicate with the Practice via secure messaging. Please note that all
communication via the Patient Portal will be included in your permanent patient record.

If the portal is malfunctioning, an alternative video chat, or phone chat may be utilized in its place.  
Patient Information and Patient Responsibilities
 The Patient Portal and secure apps allow you to communicate with the Practice via secure messaging. Please note that all
communication via the Patient Portal will be included in your permanent patient record.

Electronic communications will be viewed by not only the provider, but the staff members assigned to handle
such communications and any other provider covering for the patient’s provider if the patient’s provider is
unavailable to respond.

Please note that online communications should never be used for emergency communications or urgent requests.

Follow-up is solely your responsibility. You are responsible for scheduling any necessary appointments and for
determining if an online communication did not receive a response.

You are responsible for taking steps to protect yourself from unauthorized use of online communications, such as
keeping your password confidential. The Practice is not responsible for breaches of confidentiality caused by you
or an independent third-party

The Practice may stop providing online communications with you or change the services provided online at any
time without prior notification to you
Ways to keep your data safe
Take steps to keep your online communications to and from the Practice confidential, including:
Do not store messages on your employer-provided devices (e.g. computer, cell phone, tablet, etc.); otherwise
personal information could be accessible or owned by your employer.

Use a screen saver or close your messages instead of leaving your messages on the screen for passersby to read
and keep your password safe and private.

Do not allow other individuals or third parties access to the devices(s) upon which you store medical
communications.

Keep your login and password information secure and confidential.
Do not use email for medical communications. Standard email lacks the necessary security and privacy features
and may expose medical communications to employers or other unintended third-parties.
Emergencies: Please note that online communications should never be used for emergency communications or urgent requests. *
Required
Messaging: App Messaging, email, or other means of communication are not to be used for urgent or emergent needs.  If you are experiencing an emergency, you must call 911.  We are available M-F EST during business hours.  Please allow 48 business hours for us to formulate a thoughtful reply.  MESSAGES ARE NOT FOR URGENT NEEDS.  MASSAGING IS TO BE USED AS A SUPPLEMENT TO CLARIFY AND ASSIST BETWEEN APPOINTMENTS.   *
Required
I understand the risks associated with online communications between me and my provider's office. I consent to the conditions outlined and I agree to keep my password confidential and notify the office if my email address changes at any time.  All of my questions have been answered and I understand and concur with the information *
Required
Holistic, adjunct therapies and health coaching should not replace or interfere with the care of a medical provider.  I understand that it is my responsibility to consult my NP/PA/MD/DO or PCP prior to making any changes.  The holistic practitioner will not diagnose conditions or prescribe medications.  By clicking agree, I give my consent to a holistic wellness session.  I understand what it entails, as well as the cost of each session. *
Required
Holistic RI Practitioner Permission - I give permission for Holistic RI practitioners and providers to review this intake and share clinical  findings. Only practitioners providing direct therapies or consulting will access this information. We take your privacy very seriously. *
Required
Required
General Terms of Use
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