TREATMENT CONSENT
Effective Date: 03/01/2025
This Treatment Consent Form (“Consent”) outlines your agreement to receive medical and behavioral health services from DrGmed, Inc through GloriaONeill.com. These services may be provided via telehealth or in-person visits.
By navigating this Consent, you confirm that you have read, understood, and agree to the terms below.
1. CONSENT TO TREATMENT
I voluntarily consent to receive medical, psychiatric, and/or behavioral health treatment from healthcare professionals affiliated with DrGmed, Inc. This consent applies to both telehealth and in-person services, including medical evaluations, diagnosis, and treatment, medication management, psychiatric and mental health treatment, behavioral health counseling, substance use disorder (SUD) and Medication-Assisted Treatment (MAT) for Opioid Use Disorder (OUD), and preventive care and wellness screenings.
I understand that treatment may involve diagnostic procedures, medication prescriptions, therapy, and recommendations for further medical interventions as deemed necessary by my provider.
I understand that my treatment plan may change over time based on my progress and response to care.
2. TELEHEALTH CONSENT
If I choose to receive telehealth services, I understand that telehealth involves remote consultations via video, phone, or electronic communication. My provider will rely on the information I provide to make medical decisions and may not be able to perform a physical examination as they would in person. Telehealth is subject to limitations, including technology disruptions and the inability to assess certain conditions.
I must be physically located in the state of New Mexico at the time of my telehealth appointment. Prescriptions for controlled substances will only be issued in compliance with federal, state, and DEA regulations, and I may be required to complete an in-person evaluation before receiving certain medications. I may be required to follow up with an in-person visit if my provider determines that remote care is insufficient. My telehealth visit may be documented and stored in my electronic medical record (EMR).
3. IN-PERSON SERVICES CONSENT
If I receive in-person treatment, I acknowledge that my provider may conduct physical exams, lab tests, and in-office procedures as part of my treatment. I will comply with clinic policies, including appointment attendance, behavioral expectations, and safety guidelines. I may be required to follow COVID-19 or other public health precautions when receiving in-person care. If my provider deems necessary, I may be referred to a specialist or hospital for further evaluation.
4. RISKS & BENEFITS OF TREATMENT
I understand that, as with any medical treatment, there are both risks and benefits to the services I receive.
Potential Benefits: Improved health outcomes with proper diagnosis and treatment, access to care via telehealth when in-person visits are not feasible, medication management and behavioral therapy to address psychiatric or substance use disorders.
Potential Risks: Possible side effects from medications or treatments, limited assessment capabilities with telehealth (e.g., no physical examination), unexpected medical complications that require further intervention, technology-related issues during telehealth visits.
5. CONFIDENTIALITY & PRIVACY
I understand that my medical information is protected under HIPAA and other privacy laws. My health records will be kept confidential and only shared as required by law or with my consent. My telehealth consultations will not be recorded without my written permission. My provider may disclose information if legally required (e.g., in cases of abuse, self-harm, or public health risks).
6. APPOINTMENTS, CANCELLATIONS & PAYMENTS
I understand that I am responsible for scheduling and attending my appointments. If I need to cancel or reschedule, I must provide at least 24 hours’ notice to avoid a cancellation fee. If I do not attend a scheduled appointment without prior notice, I may be charged a no-show fee. I understand that I am responsible for any applicable co-pays, deductibles, or self-pay fees if my insurance does not cover my treatment.
7. PRESCRIPTIONS & MEDICATION MANAGEMENT
If my provider prescribes medication, I agree to follow all usage instructions and notify my provider of any side effects. Certain medications, including controlled substances, will only be prescribed after an appropriate evaluation. Controlled substances will be prescribed in compliance with DEA, federal, and state regulations. I may be required to undergo random drug screenings if receiving medication for substance use disorder.
8. PATIENT RESPONSIBILITIES
I agree to provide accurate and complete medical history to my provider. I will follow the treatment plan provided by my healthcare professional. I will notify my provider of any medication side effects or worsening symptoms. I will respect all staff, providers, and other patients in clinical settings. I will follow up with in-person care if required by my provider.
9. EMERGENCY SITUATIONS
I understand that telehealth and routine medical visits are not a substitute for emergency care. If I experience a medical emergency, I will call 911 or go to the nearest emergency room. My provider may refer me to in-person care if my condition requires immediate physical evaluation.
10. VOLUNTARY CONSENT & RIGHT TO WITHDRAW
I acknowledge that this Consent is voluntary, and I may withdraw it at any time by notifying my provider in writing. I understand that withdrawing consent does not affect prior treatments or obligations. My provider may discontinue treatment if they determine that telehealth or in-person care is not appropriate for my condition.
11. CONTACT INFORMATION
If I have any questions about my treatment, appointments, or this Consent, I can contact:
DrGmed, Inc
400 Gold Ave SW, Albuquerque, NM 87102
Simms Building (Office # 1060)
Phone: (505) 601-5662
By navigating this Treatment Consent Form, I acknowledge that I have read, understood, and accepted the terms outlined above. Also, you might have to accept other conditions during the consultation, whether through telehealth or in person.
—
Gloria O’Neill
DNP, APRN, FNP, PMHNP-BC
TREATMENT CONSENT
Effective Date: 03/01/2025
This Treatment Consent Form (“Consent”) outlines your agreement to receive medical and behavioral health services from DrGmed, Inc through GloriaONeill.com. These services may be provided via telehealth or in-person visits.
By navigating this Consent, you confirm that you have read, understood, and agree to the terms below.
1. CONSENT TO TREATMENT
I voluntarily consent to receive medical, psychiatric, and/or behavioral health treatment from healthcare professionals affiliated with DrGmed, Inc. This consent applies to both telehealth and in-person services, including medical evaluations, diagnosis, and treatment, medication management, psychiatric and mental health treatment, behavioral health counseling, substance use disorder (SUD) and Medication-Assisted Treatment (MAT) for Opioid Use Disorder (OUD), and preventive care and wellness screenings.
I understand that treatment may involve diagnostic procedures, medication prescriptions, therapy, and recommendations for further medical interventions as deemed necessary by my provider.
I understand that my treatment plan may change over time based on my progress and response to care.
2. TELEHEALTH CONSENT
If I choose to receive telehealth services, I understand that telehealth involves remote consultations via video, phone, or electronic communication. My provider will rely on the information I provide to make medical decisions and may not be able to perform a physical examination as they would in person. Telehealth is subject to limitations, including technology disruptions and the inability to assess certain conditions.
I must be physically located in the state of New Mexico at the time of my telehealth appointment. Prescriptions for controlled substances will only be issued in compliance with federal, state, and DEA regulations, and I may be required to complete an in-person evaluation before receiving certain medications. I may be required to follow up with an in-person visit if my provider determines that remote care is insufficient. My telehealth visit may be documented and stored in my electronic medical record (EMR).
3. IN-PERSON SERVICES CONSENT
If I receive in-person treatment, I acknowledge that my provider may conduct physical exams, lab tests, and in-office procedures as part of my treatment. I will comply with clinic policies, including appointment attendance, behavioral expectations, and safety guidelines. I may be required to follow COVID-19 or other public health precautions when receiving in-person care. If my provider deems necessary, I may be referred to a specialist or hospital for further evaluation.
4. RISKS & BENEFITS OF TREATMENT
I understand that, as with any medical treatment, there are both risks and benefits to the services I receive.
Potential Benefits: Improved health outcomes with proper diagnosis and treatment, access to care via telehealth when in-person visits are not feasible, medication management and behavioral therapy to address psychiatric or substance use disorders.
Potential Risks: Possible side effects from medications or treatments, limited assessment capabilities with telehealth (e.g., no physical examination), unexpected medical complications that require further intervention, technology-related issues during telehealth visits.
5. CONFIDENTIALITY & PRIVACY
I understand that my medical information is protected under HIPAA and other privacy laws. My health records will be kept confidential and only shared as required by law or with my consent. My telehealth consultations will not be recorded without my written permission. My provider may disclose information if legally required (e.g., in cases of abuse, self-harm, or public health risks).
6. APPOINTMENTS, CANCELLATIONS & PAYMENTS
I understand that I am responsible for scheduling and attending my appointments. If I need to cancel or reschedule, I must provide at least 24 hours’ notice to avoid a cancellation fee. If I do not attend a scheduled appointment without prior notice, I may be charged a no-show fee. I understand that I am responsible for any applicable co-pays, deductibles, or self-pay fees if my insurance does not cover my treatment.
7. PRESCRIPTIONS & MEDICATION MANAGEMENT
If my provider prescribes medication, I agree to follow all usage instructions and notify my provider of any side effects. Certain medications, including controlled substances, will only be prescribed after an appropriate evaluation. Controlled substances will be prescribed in compliance with DEA, federal, and state regulations. I may be required to undergo random drug screenings if receiving medication for substance use disorder.
8. PATIENT RESPONSIBILITIES
I agree to provide accurate and complete medical history to my provider. I will follow the treatment plan provided by my healthcare professional. I will notify my provider of any medication side effects or worsening symptoms. I will respect all staff, providers, and other patients in clinical settings. I will follow up with in-person care if required by my provider.
9. EMERGENCY SITUATIONS
I understand that telehealth and routine medical visits are not a substitute for emergency care. If I experience a medical emergency, I will call 911 or go to the nearest emergency room. My provider may refer me to in-person care if my condition requires immediate physical evaluation.
10. VOLUNTARY CONSENT & RIGHT TO WITHDRAW
I acknowledge that this Consent is voluntary, and I may withdraw it at any time by notifying my provider in writing. I understand that withdrawing consent does not affect prior treatments or obligations. My provider may discontinue treatment if they determine that telehealth or in-person care is not appropriate for my condition.
11. CONTACT INFORMATION
If I have any questions about my treatment, appointments, or this Consent, I can contact:
DrGmed, Inc
400 Gold Ave SW, Albuquerque, NM 87102
Simms Building (Office # 1060)
Phone: (505) 601-5662
By navigating this Treatment Consent Form, I acknowledge that I have read, understood, and accepted the terms outlined above. Also, you might have to accept other conditions during the consultation, whether through telehealth or in person.
—
Gloria O’Neill
DNP, APRN, FNP, PMHNP-BC