Telemedicine and Cannabinoid Treatment Informed Consent
Private, self-pay telemedicine practice | Texas Compassionate Use Program
Patient’s full legal name:
____________________________________________________________________________
Date of birth:
____________________________________________________________________________
Please read both parts carefully. Ask Dr. Rivers any questions before signing. You may decline or withdraw consent, but doing so may prevent the practice from providing services that depend on telemedicine or cannabinoid treatment.
Part I — Consent to Telemedicine Services
Nature of telemedicine:
Telemedicine uses secure electronic communications, audio, video, digital records, and related technology to permit medical care when the physician and patient are in different locations. A telemedicine visit may include history-taking, visual observation, review of records, clinical decision-making, education, treatment planning, prescribing when lawful and medically appropriate, and follow-up.
Patient responsibilities:
☐ I will be physically located in Texas during each telemedicine visit.
☐ I will provide my current physical location and a working telephone number at the beginning of each visit.
☐ I will participate from a reasonably private, quiet, well-lighted location and will not record the visit without prior written agreement.
☐ I will not participate while driving or operating machinery.
☐ I will identify every person present with me and obtain Dr. Rivers’ agreement before another person participates.
☐ I will provide complete and accurate information and notify the practice of material changes.
Benefits and limitations:
Potential benefits include access to physician care without travel, continuity, convenience, and timely review of records and symptoms.
Telemedicine may limit physical examination, vital-sign measurement, diagnostic testing, and the physician’s ability to detect findings apparent during an in-person examination.
Dr. Rivers may conclude that telemedicine is insufficient and may require an in-person examination, testing, specialist consultation, additional records, or emergency evaluation.
Technology can fail or be interrupted. If video fails, the visit may continue by telephone when clinically appropriate or may be rescheduled.
Although reasonable safeguards are used, no electronic system can eliminate every privacy or security risk.
Emergencies and alternatives:
This practice does not provide emergency or urgent care and does not continuously monitor messages. In an emergency, call 911 or go to the nearest emergency department. Alternatives to telemedicine include in-person care from another physician or facility and declining the service.
Privacy:
The practice will use reasonable administrative, technical, and physical safeguards. Telemedicine information is documented in the medical record. Uses and disclosures of protected health information are described in the Notice of Privacy Practices.
Patient initials: __________ I have read Part I, understand the nature, benefits, risks, limitations, and alternatives to telemedicine, and consent to receive telemedicine services.
Part II — Consent to Cannabinoid Treatment
Nature and purpose
Treatment available through the Texas Compassionate Use Program may involve a prescription for low-THC cannabis entered by a qualified physician in the Compassionate Use Registry of Texas (CURT). Treatment is considered only if Dr. Rivers independently determines that legal requirements are satisfied and that potential benefit is reasonable in light of potential risk. A consultation does not guarantee a prescription or particular result.
Potential benefits:
Depending on the patient and condition, possible benefits may include improvement in symptoms such as pain, spasticity, seizures, nausea, appetite, sleep, or other condition-related symptoms. Benefits are uncertain, vary among individuals, and may not occur.
Potential risks and adverse effects:
Drowsiness, dizziness, fatigue, impaired coordination, slowed reaction time, falls, or impaired driving.
Difficulty with attention, memory, judgment, or other cognitive effects.
Anxiety, panic, agitation, mood changes, paranoia, hallucinations, or psychosis, particularly in susceptible individuals.
Dry mouth, nausea, vomiting, diarrhea, appetite or weight changes, headache, or cardiovascular effects such as changes in heart rate or blood pressure.
Drug interactions, including additive sedation or impairment with alcohol, opioids, benzodiazepines, sleep medications, antihistamines, muscle relaxants, or other substances.
Tolerance, dependence, problematic use, withdrawal symptoms, or use outside the treatment plan.
Unknown or incompletely understood long-term effects; risks may be greater during pregnancy, breastfeeding, adolescence, advanced age, or serious medical or psychiatric illness.
Product potency and individual response can vary. Medication may impair work, driving, caregiving, or other safety-sensitive activities.
Safety obligations:
☐ I will use only the product, route, amount, and schedule recommended by Dr. Rivers and dispensed through a Texas-licensed dispensing organization.
☐ I will not smoke cannabis, share or sell medication, obtain it for another person, or allow another person to use it.
☐ I will store medication securely, in its original labeled container, away from children, visitors, pets, and anyone for whom it was not prescribed.
☐ I will not drive, operate machinery, handle firearms, work at heights, or perform other safety-sensitive activities while impaired.
☐ I will avoid alcohol and will discuss other sedating substances and medications with Dr. Rivers.
☐ I will promptly report significant adverse effects, pregnancy, breastfeeding, new medications, hospitalization, emergency care, psychiatric deterioration, or suspected misuse.
☐ I understand that employers, licensing bodies, federal programs, other jurisdictions, and private organizations may apply rules different from Texas law.
Alternatives and continuing care:
Alternatives may include no cannabinoid treatment, continued current care, medication changes, physical or behavioral therapy, procedures, specialist care, or other treatments appropriate to the condition. The practice does not replace primary care, psychiatric care, emergency care, or necessary specialty care.
Stopping treatment:
Dr. Rivers may reduce, pause, or discontinue treatment when risks exceed potential benefits, required information or follow-up is not provided, the patient is not following the treatment plan, diversion or unsafe use is suspected, the patient no longer meets legal requirements, or continuation is otherwise not medically appropriate.
Patient initials: __________ I have read Part II, understand the potential benefits, risks, uncertainties, alternatives, and safety obligations, and consent to cannabinoid treatment if Dr. Rivers determines it is medically and legally appropriate.
Combined acknowledgment and consent
☐ I had an opportunity to ask questions and received answers I understand.
☐ I understand that I may withdraw consent in writing, but withdrawal does not reverse actions already taken and may end services that depend on this consent.
☐ I understand that no outcome, program eligibility, prescription, or continued treatment is guaranteed.
☐ I authorize documentation of this consent in my medical record and acknowledge that I will receive a copy.
Patient’s printed name:
____________________________________________________________________________
Patient’s signature:
____________________________________________________________________________
Date and time:
____________________________________________________________________________
Parent, guardian, or legally authorized representative, if applicable:
____________________________________________________________________________
Representative’s signature and relationship to patient:
____________________________________________________________________________
Witness or electronic-signature audit information, if used:
____________________________________________________________________________
FRANKLIN M. RIVERS JR., MD PA
PATIENT AGREEMENT
Private, self-pay telemedicine practice | Texas Compassionate Use Program
Patient’s full legal name:
____________________________________________________________________________
Date of birth:
____________________________________________________________________________
This agreement describes the responsibilities that support a safe, respectful, and continuing physician-patient relationship in this deliberately limited practice.
Accuracy and communication:
☐ I will provide complete, truthful, and current information about my diagnoses, symptoms, medications, allergies, treatment, cannabis or substance use, other clinicians, and changes in my health.
☐ I will use the secure patient portal for medical information and will not send protected medical information through ordinary email or text message.
☐ I will keep my contact information current and respond to reasonable practice communications.
☐ I understand that portal messages are not continuously monitored and are not appropriate for emergencies.
Appointments and follow-up
☐ I will attend scheduled visits from a private location while physically present in Texas.
☐ I will provide requested records, laboratory information, referrals, or specialist evaluations before deadlines established by the practice.
☐ I will participate in follow-up at the interval determined by Dr. Rivers; continuation of treatment depends on clinically appropriate follow-up.
☐ I will notify the practice as soon as possible if I must cancel or reschedule and understand that the Financial Policy governs late cancellations and missed appointments.
Medication and safety
☐ I will follow the treatment plan and will not independently increase, decrease, combine, or transfer cannabinoid medication.
☐ I will obtain prescribed low-THC cannabis only from a Texas-licensed dispensing organization and will keep it secure.
☐ I will not seek duplicative cannabinoid prescriptions from another CURT physician while under Dr. Rivers’ care.
☐ I will inform Dr. Rivers of controlled substances, sedatives, alcohol use, nonprescribed substances, adverse effects, pregnancy, breastfeeding, or safety-sensitive work.
☐ I will comply with laws and will not drive or perform hazardous activities while impaired.
Scope of the practice
The practice is limited to telemedicine evaluation and continuing care within its stated scope. It does not provide comprehensive primary care, emergency care, or continuous on-call coverage.
Dr. Rivers may communicate with referring and treating clinicians as permitted by law and by any required authorization.
The practice may decline or end the relationship for nonpayment, repeated missed visits, abusive or threatening conduct, material misrepresentation, unsafe use, diversion, failure to provide required information or follow-up, relocation outside Texas, or other clinically or legally appropriate reasons.
When feasible and appropriate, the practice will provide notice and information about obtaining alternate care. Immediate termination may occur when necessary for safety, fraud, diversion, threats, or other serious circumstances.
Respectful conduct:
☐ I will communicate respectfully with Dr. Rivers and all persons assisting the practice.
☐ I understand that abusive, discriminatory, threatening, sexually inappropriate, fraudulent, or harassing conduct is not accepted.
Acknowledgment:
☐ I have read and understand this Patient Agreement.
☐ I understand that violation of this agreement may result in modification or discontinuation of treatment or termination from the practice.
☐ I understand that questions about this agreement may be discussed with Dr. Rivers before I sign.
Patient’s printed name:
____________________________________________________________________________
Patient’s signature:
____________________________________________________________________________
Date and time:
____________________________________________________________________________
Parent, guardian, or legally authorized representative, if applicable:
____________________________________________________________________________
Representative’s signature and relationship to patient:
_________________________________________________________________________