TELEHEALTH & IN-PERSON RESPIRATORY TREATMENT AGREEMENT
Let’s Talk Respiratory, LLC
[850 364-0162]
Patient Name: ___________________________
Date of Birth: ___________________________
Phone Number: ___________________________
Email: ___________________________
This agreement is made between Let’s Talk Respiratory, LLC (“Provider”) and the undersigned patient (“Patient”) or their legal representative.
1. Scope of Services
Provider offers telehealth and in-person respiratory therapy consultations, including but not limited to:
• Education on respiratory conditions and home therapies
• Equipment setup and troubleshooting (e.g., CPAP, BiPAP, nebulizers, oxygen therapy)
• Non-emergent respiratory management advice
• Recommendations for optimizing home respiratory care
These services are NOT a substitute for emergency medical care or direct physician supervision.
2. Emergency Protocol & Limitations
• Non-Emergency Services: The Provider offers consultations for home respiratory care and troubleshooting but does not diagnose, prescribe medications, or provide emergency medical treatment.
• Emergencies: If at any point the patient experiences difficulty breathing, chest pain, confusion, or other signs of a medical emergency, they should call 911 or go to the nearest emergency room immediately.
• No Medical Liability for Emergencies: The Provider is not responsible for worsening conditions requiring emergency intervention.
3. Patient Responsibilities
• Provide accurate and complete medical history and respiratory condition details.
• Understand that telehealth has limitations compared to in-person healthcare.
• Seek medical attention immediately if symptoms worsen or become life-threatening.
• Follow up with their primary care physician or specialist as needed.
4. Licensing & Business Liability
• Licensure Disclosure: The Provider is a licensed Respiratory Therapist in the state of [Your State] and follows all applicable laws and regulations.
• No Medical Diagnosis or Treatment: This service is educational and advisory. The Provider does not act as a physician and does not prescribe medications or make formal diagnoses.
• Limited Liability: By signing this agreement, the patient understands that Let’s Talk Respiratory, LLC and its representatives are not liable for any medical complications, emergencies, or misinterpretations of telehealth assessments.
5. Consent to Telehealth Services
By signing below, the patient acknowledges and agrees to receive telehealth services under the conditions stated in this agreement.
Patient Signature: ___________________________ Date: _______________
Provider Signature: ___________________________ Date: _______________
