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Patient Agreement

ONE HEALTH CLINIC

PATIENT SELF-PAY TELEHEALTH SERVICES, PAYMENT, CANCELLATION & PRIVACY AGREEMENT

This Patient Self-Pay Telehealth Services, Payment, Cancellation & Privacy Agreement (“Agreement”) is entered into between the individual receiving healthcare services (“Patient”) and One Health Clinic and/or the applicable affiliated professional practice or licensed healthcare provider providing services through One Health Clinic (collectively, “Clinic”).

This Agreement establishes the terms and conditions governing the Patient’s use of One Health Clinic’s self-pay telehealth services in the United States and Canada.

By booking an appointment, submitting payment, electronically accepting this Agreement, or receiving services through One Health Clinic, the Patient acknowledges and agrees to the following terms.

1. TELEHEALTH SERVICES

1.1 Video Visits

One Health Clinic provides scheduled healthcare services through telehealth. All scheduled medical appointments are conducted remotely by video visit using an electronic communication platform designated or approved by the Clinic.

1.2 Scope of Services

Depending on the Patient’s medical needs, location, and the professional judgment of the treating provider, services may include:

  • Medical consultations and evaluations;

  • Assessment of symptoms and medical concerns;

  • Review of medical history and available medical records;

  • Diagnosis and treatment recommendations;

  • Preventive and general medical care;

  • Follow-up care;

  • Referrals to specialists or other healthcare services;

  • Ordering laboratory or diagnostic testing when appropriate; and

  • Prescribing medications when medically appropriate and legally permitted.

The particular services available may vary depending on the Patient’s location, the provider’s licensure, applicable law, and the nature of the Patient’s medical condition.

1.3 Limitations of Telehealth

The Patient understands that telehealth has limitations compared with an in-person medical examination.

A treating provider may determine that the Patient’s condition cannot be safely or adequately evaluated or treated through telehealth and may recommend an in-person examination, laboratory testing, diagnostic imaging, specialist consultation, urgent care, or emergency department evaluation.

Payment for a consultation does not guarantee that the Patient’s medical concern can be fully addressed through telehealth.

2. PROVIDER MATCHING AND PATIENT LOCATION

2.1 Location-Based Provider Matching

At the time of booking, the Patient will be required to identify the U.S. state or Canadian province or territory in which the Patient expects to be physically located at the time healthcare services are provided.

One Health Clinic utilizes technology, which may include automated or artificial intelligence-assisted systems, to facilitate scheduling and match or route Patients to an available healthcare provider who is eligible to provide care to the Patient in the applicable jurisdiction.

2.2 Accuracy of Patient Location

The Patient is responsible for providing accurate location information.

The Patient may be required to confirm their physical location at the beginning of the video appointment.

If the Patient is physically located in a jurisdiction where the assigned provider cannot legally provide healthcare services, the Clinic may reassign, reschedule, or cancel the appointment.

2.3 Clinical Decision-Making

Automated or artificial intelligence-assisted technology may assist with administrative functions, including scheduling and provider matching.

Such technology does not independently diagnose the Patient, determine treatment, prescribe medication, or replace the independent professional judgment of the treating healthcare provider.

All diagnosis, treatment, prescribing, referral, and other clinical decisions are made by the treating healthcare professional.

3. SELF-PAY SERVICES

3.1 Direct-Pay Practice

One Health Clinic operates on a self-pay/direct-pay basis.

The Patient is financially responsible for all services booked through the Clinic.

Unless expressly stated otherwise, One Health Clinic does not submit claims to Medicare, Medicaid, provincial health insurance plans, private insurance companies, employer health plans, or other third-party payers on the Patient’s behalf.

3.2 Insurance Reimbursement

The Patient may independently submit receipts or documentation to an insurer or other third party when permitted.

One Health Clinic makes no representation or guarantee that any appointment, consultation, treatment, prescription, test, or other service will qualify for reimbursement.

The Patient remains responsible for the appointment fee regardless of whether reimbursement is available.

4. FEES AND PAYMENT

4.1 Appointment Pricing

The price of the selected service will be disclosed to the Patient before the booking and payment process is completed.

Fees may vary depending upon the type, duration, or complexity of the service selected.

4.2 Payment Required Before Appointment

Full payment is required before the scheduled appointment.

The Clinic may require payment at the time of booking. An appointment is not considered fully confirmed until the required payment has been successfully processed.

4.3 Payment Authorization

By providing a payment method, the Patient authorizes One Health Clinic and its authorized payment processor to charge the disclosed appointment fee and any other fees expressly authorized under this Agreement.

5. 72-HOUR CANCELLATION AND RESCHEDULING POLICY

5.1 Required Notice

Patients must provide One Health Clinic with at least seventy-two (72) hours’ notice before the scheduled appointment time to cancel or request to reschedule an appointment without being subject to the late-cancellation policy.

5.2 Late Cancellations

An appointment cancelled with less than 72 hours’ notice may be considered a late cancellation.

The appointment fee may be retained and may be non-refundable, subject to applicable law and any exception approved by the Clinic.

5.3 Rescheduling

Requests to reschedule made at least 72 hours before the scheduled appointment may be transferred to another available appointment, subject to provider availability and Clinic policy.

Requests made less than 72 hours before the scheduled appointment may be treated as a late cancellation.

6. NO-SHOW POLICY

A Patient who fails to attend a scheduled appointment without timely cancellation will be considered a no-show.

The no-show fee is equal to the full cost of the appointment booked.

Because payment is collected before the appointment, the Clinic may retain the full prepaid appointment fee when a Patient fails to attend the appointment.

For purposes of this policy, a Patient may also be considered a no-show when the Patient fails to join the video appointment within a reasonable period after the scheduled appointment time and the provider is no longer reasonably able to complete the scheduled consultation.

Any no-show fee or retention of a prepaid appointment fee remains subject to applicable law.

7. REFUND POLICY

Except where otherwise required by applicable law or approved by the Clinic:

  • Appointments cancelled at least 72 hours before the scheduled appointment are eligible for cancellation or rescheduling in accordance with Clinic policy.

  • Appointments cancelled less than 72 hours before the scheduled appointment may be non-refundable.

  • No-shows are charged the full cost of the appointment booked.

  • Payment for a completed medical consultation is generally non-refundable merely because the Patient disagrees with the provider’s clinical assessment or does not receive a particular requested treatment, prescription, referral, test, letter, form, or other outcome.

  • If the Clinic is unable to provide the scheduled appointment because of provider unavailability or circumstances attributable to the Clinic, the Patient may be offered a replacement provider, rescheduled appointment, or refund, as appropriate.

Nothing in this Agreement limits refund or consumer rights that cannot lawfully be waived.

8. PRESCRIPTIONS, REFERRALS AND MEDICAL DOCUMENTATION

Payment for an appointment is payment for the healthcare professional’s evaluation and professional services.

Payment does not guarantee a prescription.

It also does not guarantee a particular medication, controlled medication, laboratory order, diagnostic test, referral, medical certificate, disability form, work note, accommodation letter, clearance, or other requested medical documentation.

The treating provider will independently determine what treatment, prescribing, testing, referrals, and documentation are medically appropriate.

Prescribing is subject to applicable federal, state, provincial, territorial, licensing, and professional requirements.

9. PATIENT RESPONSIBILITIES

The Patient agrees to:

a. Provide accurate identifying, contact, payment, medical, and location information;

b. Provide complete and truthful information regarding symptoms, medical history, medications, allergies, and other information relevant to care;

c. Inform the provider of significant changes in the Patient’s medical condition;

d. Accurately identify the jurisdiction where the Patient is physically located during the appointment;

e. Participate from a reasonably private and appropriate location;

f. Maintain a device, camera, microphone, and internet connection reasonably capable of supporting the video appointment;

g. Attend the appointment at the scheduled time; and

h. Seek in-person, urgent, or emergency medical attention when recommended or medically necessary.

10. EMERGENCY MEDICAL CONDITIONS

One Health Clinic’s scheduled telehealth service is not an emergency medical service and should not be used as a substitute for emergency care.

Patients experiencing a medical emergency should not wait for a One Health Clinic appointment.

The Patient should immediately contact the appropriate local emergency service or proceed to the nearest emergency department when experiencing a medical emergency.

11. TELEHEALTH CONSENT

By accepting this Agreement and participating in a video appointment, the Patient voluntarily consents to receiving healthcare through telehealth.

The Patient understands that telehealth may offer benefits including convenience and improved access to healthcare but may also involve limitations and risks.

These may include:

  • Limitations on the provider’s ability to conduct a physical examination;

  • Technical interruptions or equipment failures;

  • Delays resulting from technology problems;

  • The possibility that an in-person examination or additional testing will ultimately be required; and

  • Privacy or security risks inherent in electronic communications despite reasonable safeguards.

The Patient may ask questions regarding telehealth and may withdraw consent to telehealth, subject to the consequences of discontinuing a consultation and the cancellation/refund provisions of this Agreement.

12. PRIVACY AND CONFIDENTIALITY

12.1 Collection of Information

One Health Clinic and its healthcare providers may collect information reasonably necessary to provide healthcare and operate the telehealth service, including:

  • Identifying and contact information;

  • Medical history and health information;

  • Appointment and scheduling information;

  • Communications between the Patient and Clinic;

  • Billing and payment-related information; and

  • Information necessary for medical recordkeeping and regulatory compliance.

12.2 Use of Information

Patient information may be used as reasonably necessary to:

  • Provide and coordinate healthcare;

  • Maintain medical records;

  • Communicate with the Patient;

  • Schedule and manage appointments;

  • Process payments;

  • Match Patients with appropriate providers;

  • Operate and improve Clinic services;

  • Meet professional, regulatory, legal, and compliance obligations; and

  • Protect the Patient, providers, Clinic, or others when legally required or permitted.

12.3 Protection of Patient Information

The Clinic will take reasonable administrative, technical, and organizational measures to protect personal and health information from unauthorized access, use, alteration, or disclosure.

The Clinic will handle Patient information in accordance with privacy and healthcare requirements applicable to the Patient, provider, and entity providing the healthcare service.

Because One Health Clinic serves Patients in the United States and Canada, applicable privacy requirements may vary according to jurisdiction.

12.4 Electronic Communications

The Patient understands that electronic communications and telehealth technologies may involve privacy and security risks despite reasonable safeguards.

By using the Clinic’s electronic services, the Patient consents to communications reasonably necessary for scheduling, providing, coordinating, and administering the Patient’s care, subject to applicable law.

13. TECHNOLOGY AND VIDEO CONNECTIONS

The Clinic does not guarantee uninterrupted availability of its website, scheduling system, payment processor, video platform, or other technology.

If technical difficulties prevent a meaningful video consultation, the provider or Clinic may attempt to reconnect or may determine that the appointment should be rescheduled.

Technical issues attributable to the Clinic or provider will be handled reasonably by the Clinic, including rescheduling or refunding the appointment when appropriate.

Technical difficulties attributable to the Patient may be treated according to the cancellation and no-show provisions of this Agreement, subject to applicable law and Clinic discretion.

14. NO GUARANTEE OF MEDICAL OUTCOME

Healthcare involves uncertainty.

Neither One Health Clinic nor an individual treating provider guarantees any particular diagnosis, treatment result, recovery, prescription, referral, medical document, or other outcome.

The Patient understands that the appointment fee compensates the Clinic and/or provider for the professional healthcare service provided rather than for any particular requested result.

15. GOVERNING LAW AND JURISDICTION-SPECIFIC REQUIREMENTS

Healthcare services provided through One Health Clinic are subject to applicable federal, state, provincial, territorial, and local laws and the licensing and professional requirements applicable to the treating provider and Patient.

Because One Health Clinic facilitates services across multiple jurisdictions in the United States and Canada, different legal requirements may apply depending upon where the Patient is physically located and which healthcare professional provides the service.

If any provision of this Agreement conflicts with a mandatory requirement of applicable law, the applicable law will control to the extent of the conflict.

Nothing in this Agreement is intended to waive, restrict, or eliminate a Patient right or legal protection that cannot lawfully be waived.

16. CHANGES TO FEES AND POLICIES

One Health Clinic may modify its fees, services, scheduling procedures, cancellation policies, or other administrative policies from time to time, subject to applicable law.

The appointment price and material booking terms presented to the Patient at the time an appointment is booked will apply to that appointment unless otherwise agreed or required by law.

17. ELECTRONIC COMMUNICATIONS AND SIGNATURES

The Patient agrees that this Agreement may be provided, acknowledged, and signed electronically.

Checking an acceptance box, providing an electronic signature, or clicking an “I Agree,” “Accept,” “Book Appointment,” “Confirm and Pay,” or similar button after being presented with this Agreement constitutes the Patient’s electronic acceptance of the Agreement to the extent permitted by applicable law.

Electronic records and signatures may be treated in the same manner as paper records and handwritten signatures where permitted by law.

18. ENTIRE AGREEMENT AND SEVERABILITY

This Agreement incorporates One Health Clinic’s terms governing telehealth services, self-pay payment obligations, appointment cancellations and no-shows, refunds, telehealth consent, and privacy practices addressed herein.

If any provision of this Agreement is determined to be invalid or unenforceable under applicable law, that provision will be interpreted or limited to the extent necessary to comply with applicable law, and the remaining provisions will continue in effect to the extent legally permitted.

19. PATIENT ACKNOWLEDGMENT AND CONSENT

By signing or electronically accepting this Agreement, the Patient acknowledges and agrees that:

  1. One Health Clinic provides scheduled medical appointments through video visits;

  2. The Patient must accurately disclose the U.S. state or Canadian province or territory where they are physically located when receiving care;

  3. Technology, including automated or AI-assisted systems, may facilitate provider matching and administrative routing;

  4. Medical decisions remain the responsibility of the treating healthcare professional;

  5. One Health Clinic operates on a self-pay/direct-pay basis;

  6. Payment is required before the appointment;

  7. At least 72 hours’ notice is required to cancel or reschedule an appointment without being subject to the late-cancellation policy;

  8. A no-show fee is equal to the full cost of the appointment booked;

  9. Payment does not guarantee a prescription, referral, medical document, diagnostic test, or particular clinical outcome;

  10. Telehealth has benefits, risks, and limitations;

  11. The Patient consents to the collection, use, maintenance, and disclosure of information as described in this Agreement and as otherwise permitted or required by applicable law; and

  12. The Patient has had the opportunity to review this Agreement before booking and paying for services.

PATIENT ACCEPTANCE

Patient Name: ______________________________________

Patient Signature / Electronic Acceptance: ______________________________________

Date: ______________________________________

ONE HEALTH CLINIC

Clinic Representative (if required): ______________________________________

Signature: ______________________________________

Date: ______________________________________

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