Patient Agreement

This Patient Purchase Agreement ("Agreement") is entered into between [Patient Name]
("Patient") and [One Health Clinic Online Inc] ("Clinic") regarding the provision of office visits, telehealth and
home visit services by licensed physicians. This Agreement outlines the terms and conditions
under which the Clinic agrees to provide healthcare services to the Patient, and the Patient
agrees to receive and pay for such services.
1. Services:
a. The Clinic agrees to provide telehealth and home visit services, including medical
consultations, evaluations, diagnoses, and treatment recommendations, as deemed appropriate
by the licensed physicians associated with the Clinic.
b. The Clinic may utilize various communication technologies, such as videoconferencing,
phone calls, or secure messaging platforms, to facilitate telehealth services.
c. Home visit services involve a licensed physician visiting the Patient's home for the purpose
of providing medical care, as agreed upon by both parties.
d. The Clinic agrees to provide medical services in the respective jurisdiction which it's network of physicians is licensed in. Patients may only book with providers if the patient is located in the providers respective state/province at the time of the visit.
2. Payment:
a. The Patient agrees to pay for the services rendered by the Clinic as outlined in the Clinic's
fee schedule, which will be provided to the Patient separately.
b. Payment for telehealth services shall be made prior to or at the time of service, as agreed
upon by the Patient and the Clinic.
c. Payment for home visit services shall be made at the time of service or as otherwise
arranged between the Patient and the Clinic.
d. The Patient understands and agrees that payment is the responsibility of the Patient, and
the Clinic may assist in submitting insurance claims, if applicable. However, any unpaid
balances not covered by insurance are the Patient's responsibility.
3. Cancellation and Rescheduling:
a. The Patient agrees to provide the Clinic with at least 24 hours' notice for any cancellations
or rescheduling of appointments.
b. Failure to provide timely notice may result in a cancellation fee, as determined by the
Clinic's policy.
4. Privacy and Confidentiality:
a. The Clinic is committed to maintaining the privacy and confidentiality of the Patient's
personal health information in accordance with applicable laws and regulations.
b. The Patient understands and agrees that the Clinic may collect and store their personal
health information for the purpose of providing healthcare services, billing, and record-keeping.
c. The Clinic will take reasonable measures to protect the Patient's personal health
information from unauthorized access or disclosure.
5. Governing Law and Jurisdiction:
a. This Agreement shall be governed by and construed in accordance with the laws of
the respective state.
b. Any disputes arising out of or relating to this Agreement shall be subject to the exclusive
jurisdiction of the courts located in the respective state.
By signing below, the Patient acknowledges that they have read, understood, and agree to the
terms and conditions outlined in this Patient Purchase Agreement.
__________________________ _________________________
Patient Name (Print) Patient Signature
Date: _________________
__________________________ _________________________
Clinic Representative Name (Print) Clinic Representative Signature
Date: _________________
Policy for Direct Payments to Private Practice Clinic
1. Payment Methods:
a. The Clinic accepts various payment methods, including but not limited to cash, credit/debit
cards, electronic fund transfers, and mobile payment apps.
b. Payment details and accepted methods will be provided to the Patient at the time of
scheduling or registration.
2. Fee Schedule:
a. The Clinic has a predetermined fee schedule for its services, which will be provided to the
Patient separately.
b. The fee schedule may vary based on the type of service rendered, complexity, duration,
and any additional procedures or tests conducted.
c. The Patient is responsible for reviewing and understanding the fee schedule prior to
receiving services from the Clinic.
d. All Prices listed are in USD.
3. Insurance Claims:
a. The Clinic may assist with insurance claims, however, the claims are the responsibility of the patient to submit.