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Symptom / Headache questionnaire

Disclaimer of Physician-Patient Relationship for Virtual Headache Specialist Second Opinion Services

The following must be completed and acknowledged by every individual who seeks to utilize the Virtual Headache Specialist Second Opinion service provided by Virtual Medical Specialists (“VMS”). The prospective patient must check a box or electronically sign to indicate that they have read, understood, and agree to the following terms.

Purpose and Scope of Services The undersigned individual (“You”) acknowledges and agrees that the services provided by Virtual Medical Specialists (“VMS”) in connection with the review of medical records and the provision of general suggestions (the “Services”) are strictly limited in scope. These Services constitute a purely educational consultation and are intended solely for informational and educational purposes. They do not constitute medical treatment, diagnosis, or the establishment of a physician-patient relationship under the laws of the State of Ohio.

You further acknowledge that the Services are provided from Ohio and may be accessed by individuals located in other U.S. states or countries. The legal characterization and permissibility of these Services may vary by jurisdiction. It is Your responsibility to determine whether the Services are appropriate and lawful for You under the laws of Your location.

No Physician-Patient Relationship By engaging in the Services, You expressly acknowledge and agree to the following:

1. No Diagnosis or Treatment: VMS will not provide any diagnosis, treatment, or medical advice specific to Your condition, nor will it interpret any findings as diagnostic conclusions. The Services are limited to general suggestions, opinions, or educational information based solely on the information and medical records You provide. These suggestions do not constitute individualized medical advice and are not a substitute for professional medical care. Any suggestions, opinions, or educational information provided must be discussed with Your licensed treating physician or another qualified healthcare provider before You take any action. The reviewing specialist will not have the benefit of a full medical history, physical examination, or direct interaction with You.
2. Consultation with Primary Care Physician: You are advised to consult with Your primary care physician or another qualified healthcare provider regarding any medical concerns or decisions. VMS’ suggestions are intended to supplement, not replace, the advice of Your primary care physician and You agree not to rely on Your consultation with VMS as medical care and will make no health decisions based on it without evaluation and approval by Your treating primary care physician.
3. No Duty of Care: VMS does not assume any duty of care or fiduciary responsibility to You. The Services do not create any legal or ethical obligations typically associated with a physician-patient relationship. VMS does not assume any obligation to follow up, track symptoms, review new records or respond within any particular timeframe.
4. No Emergency Services: The Services are not intended for use in emergency or urgent medical situations. If You are experiencing a medical emergency, new or worsening symptoms (including but not limited to sudden severe headache, neurological changes, vision loss, or other concerning symptoms), You should immediately contact emergency services or visit the nearest emergency room.

Additional Limitations

• The Services do not include any ongoing care, prescriptions, referrals for treatment, follow-up visits, or further communications beyond the single second-opinion review.
• You are solely responsible for providing accurate, complete, and up-to-date medical records. VMS is not responsible for any incomplete, inaccurate, or outdated information You submit.
• The Services provide no guarantee of accuracy, completeness, or any particular outcome, as they are based only on the records and information You choose to provide.
• VMS makes no representation that the Services comply with the laws of every jurisdiction outside Ohio. You agree to use the Services at Your own risk with respect to any applicable laws in Your location.

Consent and Acknowledgment By signing or otherwise acknowledging this form, You confirm that:

1. You understand and agree that the Services are provided solely for informational purposes and do not establish a physician-patient relationship.
2. You understand that VMS is not Your treating physician and that You remain solely responsible for seeking appropriate medical care from a licensed healthcare provider.
3. You release VMS, its affiliates, and the reviewing specialist from any and all liability arising from the use of the Services, except as required by applicable law.

Privacy and Confidentiality VMS will comply with all applicable federal and state laws, including the Health Insurance Portability and Accountability Act (HIPAA), regarding the confidentiality and security of Your medical records and personal health information. However, You acknowledge that the Services may involve the review of Your medical records and that You voluntarily consent to such review for the limited purpose of receiving general suggestions or opinions. You acknowledge that there are certain privacy risks associated with providing records by means of electronic communications, and that in the event of a data breach, while VMS will provide notice of such a breach in accordance with applicable law, You agree to hold VMS harmless in connection wit h such breach. You further understand that privacy laws in other countries or U.S. states may differ from HIPAA.

Governing Law This agreement shall be governed by and construed in accordance with the laws of the State of Ohio. Any disputes arising from or related to the Services shall be resolved exclusively in the courts of Ohio.

Signature and Date By signing below, You acknowledge that You have read, understood, and agreed to the terms outlined in this document. You further represent that You are at least 18 years of age or are the legal guardian/authorized representative of the patient and have the legal authority to agree to these terms on their behalf.