New Patient Intake & Consent Form

I hereby give my consent to care performed by the physician/APRN at Solace Center (henceforth referred to as "the practice"). I consent to being treated by the practice using psychotropic medications, non-psychotropic medications, psychotherapy, and other forms of treatment deemed necessary and appropriate by the provider and within the provider's scope of practice.

I understand, and I am informed that, as with all healthcare treatments, results are not guaranteed and there is no promise of cure. I have had the opportunity to discuss with my provider the nature and purpose of treatments and procedures. I am aware that all existing methods of diagnosis and treatment pose some level of risk. I do not expect the provider to be able to anticipate and explain all risks and complications, and I wish to rely on the provider to exercise judgment during the course of the treatment which the provider feels at the time, based upon the facts then known, and is in my best interests.

Solace Center providers are only in the office during limited, posted hours. We do not provide out-of-office call coverage and refer to the emergency department (ED) if there are ever any concerns about health or safety. I will immediately inform the provider if I experience any unanticipated or unpleasant effects associated with treatment or prescription(s)/supplement(s) prescribed/recommended. I understand that if an emergency medical condition or mental health crisis arises, I am expected to call 9-1-1 / 988 or go to the nearest emergency room.

I, the undersigned patient, hereby authorize Solace Center, in accordance with Massachusetts state law, to request and obtain my medication history from my pharmacies, other healthcare providers, and through the Massachusetts Prescription Awareness Tool (MassPAT), a nationwide health information network that electronically exchanges medication history of scheduled medications prescribed.

This consent includes, but is not limited to, the following information:
1. Prescribed medications
2. Dosage and frequency
3. Prescribing physicians
4. Pharmacy information

I understand that this information will be used by Solace Center for the purpose of ensuring continuity of care, preventing medication errors, and providing the best possible medical treatment.

I acknowledge that I have the right to revoke this consent at any time, except to the extent that action has been taken in reliance on this consent. This consent will remain valid until such time as it is revoked in writing.

I understand that Solace Center will maintain the confidentiality of my medication history in accordance with federal and state law, and that any further release of this information will be done only with my written consent or as required by law.

I understand that the practice may recommend blood, saliva, stool, urine, hair, or skin testing within their scope of practice. In addition to conventional testing, specific tests may be ordered through specialized laboratories to assess structural and/or functional deficiencies, and may not always be diagnostic, but can provide critical information to help improve my health outcomes. I agree with the use of such tests and will always have the opportunity to discuss their applicability and limitations with my provider, prior to sample collection. I agree to pay the laboratory any fees due for sample collection and processing.

I consent to voluntarily engaging in a telemedicine consultation with the practice. I understand that the video conferencing technology will not be the same as a direct patient/health care provider visit:

Telehealth consultation has potential benefits, including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home. It also has potential risks including interruptions, unauthorized access, and technical difficulties.

I understand that my health care provider, or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

If there is another individual present during the telehealth consultation, I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence at the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through the practice will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.

Telemedicine services offered through the practice are not an Emergency Service and in the event of an emergency or urgent medical/mental health issue, I will use a phone to call 911 or go to the emergency department.

To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.

The Artificial Intelligence (AI) scribe is a tool designed to assist in documenting and transcribing our sessions accurately. It is used to enhance the quality of care, streamline administrative processes, and facilitate a more efficient and comprehensive record-keeping system.

The AI scribe is a software program that utilizes artificial intelligence technology to transcribe spoken words into written text. It does not interpret or analyze content beyond transcription. I understand that information recorded by the AI scribe is subject to the same strict confidentiality standards as our sessions, access is restricted to authorized personnel, and I have the right to opt out of its use at any time.