Please review this interim consent before continuing to the questionnaire. It explains how your intake information may be collected, organized, reviewed, shared when a clinician is involved, and stored electronically.
General Consent and Intake Authorization
By continuing, the patient acknowledges that this questionnaire is used to collect health history, symptom information, lab-related information, and related intake material for review by the appropriate clinician or WalshDoc-supported workflow.
This questionnaire is not for emergency care. If urgent or emergency medical help is needed, contact emergency services or seek immediate medical care.
Submitting this questionnaire does not by itself create an emergency medical service, primary care relationship, or ongoing physician-patient relationship with Dr. David Epstein, Second Opinion Physician, or WalshDoc unless separately agreed in writing or through a scheduled consultation.
Relationship Between Patient, Clinician, WalshDoc, and Dr. Epstein
WalshDoc is a clinical intake, lab-organization, report-preparation, and follow-up platform used to help organize biochemical and functional health assessment information.
If this questionnaire was assigned by a referring clinician or clinic, that clinician or clinic remains responsible for the patient-clinician relationship, diagnosis, treatment decisions, prescriptions, and follow-up care unless a separate consultation relationship is established with Dr. David Epstein or Second Opinion Physician.
Second Opinion Physician / WalshDoc and Dr. David Epstein may assist by receiving, organizing, reviewing, and preparing assessment information, including questionnaire responses, lab results, report language, and follow-up materials, depending on the service level selected by the clinician or patient.
Authorization to Share Information
The patient authorizes submitted information, including questionnaire responses, health history, lab results, reports, and related assessment materials, to be shared between the referring/ordering clinician or clinic, WalshDoc, Second Opinion Physician, Dr. David Epstein, participating laboratories, and secure service providers as needed for intake review, lab organization, report preparation, clinician review, follow-up tracking, billing, and related healthcare operations.
This questionnaire is associated with: Clinician / Clinic
By continuing, the patient authorizes WalshDoc / Second Opinion Physician to make the submitted information and resulting assessment materials available to that clinician or clinic for review and follow-up.
Electronic / Cloud Storage
The patient understands that submitted information may be stored and processed electronically in secure cloud-based systems used by WalshDoc / Second Opinion Physician. This may include questionnaire answers, contact information, lab values, original lab reports, clinician notes, report drafts, final reports, and follow-up information.
WalshDoc uses electronic systems and service providers intended to support secure storage, access control, backup, and clinical workflow. No electronic system can be guaranteed to be completely risk-free.