INFORMED CONSENT FOR MEDICATION

​I agree to take any medication as prescribed. I understand that prescribed medications have benefits for improving my health but that they are not without risks or side-effects. I agree to read the medication insert, popularly known as the Patient Information Sheet, provided to me by the pharmacist and will contact Dr. Gruich or the pharmacist with any questions.

I understand that every person is different with respect to their individual responses to the therapeutic and adverse effects of medications. I understand that in addition to physical side-effects, there may also be psychological or emotional side-effects. While prescription medications are generally safe and effective, I understand that Dr. Gruich is unable to guarantee me the safety or therapeutic effect of any medication prescribed by him.


Sign: ___________________________________________________________________________________________Date:________________________
                                   


​                                          CONFIDENTIALITY OF VISIT

While Dr. Gruich has offered me a prompt office visit at his local address in order to comply with HIPAA regulations, I've opted to conduct my Visit by a virtual encounter. For my Telemed Visit I choose to use a video/audio platform like Google Duo or Zoom. I understand my Telemed Visit will be private and that no other persons, other than those I choose, will be present during my Visit. While these platforms allow for confidential sharing of my medical information, I realize and accept that Dr. Gruich cannot assure me the absolute privacy of such sharing. All medical information shared during the Visit will be kept confidential by Dr. Gruich at his office and will be available to me at my request and not be released to others without my written consent.
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Sign:__________________________________________________________________________________________Date:____________________________

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