Wil Jeudy, MD Family Practice Doctor

Effects of Condition
Accompanying Symptoms (i.e. Nausea)
Sleep
Appetite
Physical Activity
Relationship w/ Others (i.e. Irritability)
Emotions (i.e. Anger, Suicidal, Crying)
Concentration
Additional Comments
Preferences
Best Time for Physician to Call
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Clinical Information

Explain Your Medical Condition
Please explain the medical reason you are seeking treatment for. Please be specific and use medical terminology if possible. Your medical records must reflect the condition you are requesting a consultation for.
TERMS OF USE
PLEASE REVIEW THE FOLLOWING TERMS AND CONDITIONS CAREFULLY AS TO AGREE WITH THE TERMS AND CONDITIONS BEFORE PROCEEDING! By viewing this website, and/or subscribing to any services made available on this website, you are subject to the terms and conditions set forth in this document. By accessing or using this Site or attempting to, or purchasing any services, you are agreeing to these Terms and Conditions. In addition, when using any particular Document or Materials on this Site, you shall be subject to any posted guidelines or rules applicable to such Services or Materials that may contain terms and conditions in addition to these terms and conditions. All such guidelines or rules are hereby incorporated by reference into these terms and conditions. If you breach any of the terms and conditions, your authorization to use this website automatically terminates and you must immediately destroy any/all materials downloaded or printed from this website. Furthermore, your right to continue receiving services whether paid for in part or in full are subject to termination for cause. You give your permission for Dr. Jeudy and our medical partners to perform and undertake an “in-person” Face-to-Face initial consultation and evaluation of you and your complaint as a potential patient and subsequent on-line medical consultation(s) as determined by the treating physician. By submitting a questionnaire for review for a consultation and possible prescription(s), you agree to release from liability and hold harmless Dr. Jeudy, its owners, their affiliates, subsidiaries, directors, officers, employees, representatives, and independent contractors from all causes of action, suits, penalties, liens, judgments, liabilities, obligations, losses, actual or consequential damages, actual or threatened claims which may arise at any time by reason of, relating to, arising directly or indirectly out of any matter whatsoever related to the prescription of your medication. This consultation is being requested by your own choice, at your own expense, and your own liability and you assume all responsibility for your use of treatments prescribed by the treating physician. You fully understand that it is your responsibility to have an annual physical examination, including any suggested laboratory tests, to ensure that you have no disease(s) that might be incompatible for your self-described condition. You further agree to immediately notify any doctor whose present care you are under that you have chosen to take a prescription prescribed by the treating physician so that they may advise to continue or discontinue use. Should you engage a new doctor's care in the future; you further agree to immediately notify said doctor of your use of treatments prescribed by Dr. Jeudy's physician(s). You hereby release Dr. Jeudy, its owners and their employees and contractors including physicians and pharmacists from any and all liability whatsoever associated or connected with your consultation and/or your use of treatments prescribed. You hereby state that you are an adult as defined in the state of which you reside. You understand that to falsify information in order to obtain prescription medication is a violation of both State and Federal US law. You hereby agree to answer truthfully all of the medical questions on the initial questionnaire and subsequent telemedicine questionnaire as applicable. You understand that no doctor, nurse, or administrative personnel can guarantee that treatments, even if prescribed, will provide the results you seek. Furthermore, you understand that even if prescribed, you may suffer adverse effects from treatments. You hereby release Dr. Jeudy and all of its employees and contractors including physicians and pharmacists from any and all liability whatsoever associated with any adverse effects you may suffer from any use of prescribed treatments including modalities. You understand that it is your responsibility to furnish Dr. Jeudy with your complete and accurate medical history and follow up hereafter with any changes to it. You understand that the proposed consultation and care may involve risks and possibilities of complications and that certain complications or side effects have been known to occur in patients who take prescribed treatments even when the utmost care, judgment, and skill are used. You acknowledge that no guarantees have been made to you as to the results of treatment or are there any guarantees against favorable results, risks, or complications. You understand and acknowledge that there is no implied warranty to you and that treatments may benefit one patient and not another. You understand that there is no known medical treatment that gives 100% satisfaction to everyone. You understand and agree that Dr. Jeudy, its owners and its employees may see any information you provide to your physician and that such information will constitute a medical record. You further understand and agree that Dr. Jeudy, your physician, or both will maintain your medical records. You understand and acknowledge that Dr. Jeudy and its physicians RECOMMEND A PHYSICAL EXAMINATION BY A DOCTOR BEFORE TAKING ANY PRESCRIBED TREATMENTS. You also ATTEST that the medical condition that you are self-describing is true and that the condition MAY BE defined as an "Emergency Medical Situation". An "Emergency Medical Situation" may be defined as "a condition of emergency in which immediate medical care or hospitalization, or both, is required by a person or persons for the preservation of health" This definition may be modified in meaning and or definition to constitute the definition of a "Temporary Doctor/Patient Relationship" in the state in which you reside and/or the doctor resides, is licensed and/or practices medicine. You acknowledge and agree that you initiated the contract with Dr. Jeudy and its medical practitioners may be located in another state from your own and that they may NOT be licensed to practice medicine in your state of residence. You fully understand and agree that if you fail in any way to furnish Dr. Jeudy with your complete and accurate medical history, or you become aware of any changes in your physical or medical condition in the future and you fail to notify Dr. Jeudy or its medical practitioners of such changes, then you agree that you are solely responsible for any adverse effects you may suffer from taking or continuing to take treatments provided prescribed by Dr. Jeudy or from participating in this program. To preclude any conflict of interest or the appearance of any conflict of interest, the only refund possible is a portion of the initial consultation fee less all fees paid to the examining physician in the usual course of practice. Should a physician elect not to treat your condition for any reason, only a portion of your initial consultation fee may be refunded upon review of Dr. Jeudy management. If approved, any such refund shall be made to you the patient in a manor mutually agreed upon at the time that the refund is approved. You understand and agree that you are responsible for all customs, tariffs, and taxes, if applicable in your state. You have read and understood the above-referenced provisions and authorize and accept the proposed terms and care regardless of the medical or legal risks and you declare that you understand the risks. If, after review of your initial consultation or subsequent telemedicine “phone” consultation, a doctor determines that a prescribed treatment is the appropriate treatment for your condition, you hereby authorize and agree to all charges. You also understand that you must initiate any and all re-prescriptions by contacting Dr. Jeudy via its' website or via telephone, and that re-prescriptions cannot be requested until 25 days after the previous medications have been received, and that all prescriptions are non-transferable. You hereby authorize shipping charges to be sent COD or Credit Card in accordance with the shipping information that you have supplied. The materials on this Site may include inaccuracies or typographical errors and are subject to change at any time. The materials are provided "as is" without warranty of any kind. In no event will Dr. Jeudy, its owners, or its suppliers be liable for indirect, special, incidental, or consequential damages, whether in an action of contract or tort, arising out of the use of or inability to use the materials available on the Site, even if advised of the possibility of such damages. In particular, and without limitation, Dr. Jeudy shall have no liability for any loss of use, data including the costs of recovering such data or profits. Copyright; Limited License the Materials and Services on this Site are protected by copyright and/or other intellectual property laws and any unauthorized use of the Materials or Services at this Site may violate such laws. Except as expressly provided herein, Dr. Jeudy and its suppliers do not grant any express or implied right to you under any patents, copyrights, trademarks, or trade secret information with respect to the Materials and Services. Except as specifically permitted herein, no portion of the information or documents on this Site may be reproduced in any form or by any means without prior written permission of Dr. Jeudy. Use of Site information. Except as otherwise indicated elsewhere on this Site, you may view, download and print the documents and information available on this Site subject to the following conditions: a. The documents and information may be used solely for personal, informational, internal, non-commercial purposes, b. The documents and information may not be modified or altered in any way, c. The documents and information on the Site may not be distributed, d. You may not remove any copyright or other proprietary notices contained in the documents and information, e. Dr. Jeudy reserves the right to revoke the authorization to view, download, and print the documents and information available on this Site at any time; and any such use shall be discontinued immediately upon written notice from Dr. Jeudy, and f. The rights granted to you constitute a license and not a transfer of title. The rights specified above to view, download and print the documents and information available on this Site are not applicable to the design of layout of this Site. Personal Information and Privacy. To learn how Dr. Jeudy protects your personal information, refer to the Dr. Jeudy Statement Regarding "Privacy" Trademark Information. The trademarks, logos and service marks ("Marks") displayed on this Site are the property of Dr. Jeudy or other third parties. You are not permitted to use the Marks without prior written consent of Dr. Jeudy or such third party which may own the Marks. Dr. Jeudy and the Dr. Jeudy logo are trademarks of the company NATIONAL NETWORK FOR CHRONIC INTRACTABLE PAIN. YOU AGREE THAT ALL ON-LINE MEDICAL CONSULTATIONS, DIAGNOSES, AND TREATMENTS WILL BE DEEMED TO HAVE OCCURRED IN THE STATE WHERE THE MEDICAL PRACTITIONERS ARE PHYSICALLY LOCATED AND LICENSED TO PRACTICE MEDICINE. YOU UNDERSTAND AND AGREE THAT YOU ARE ACCEPTING OR REJECTING THE TERMS OF THIS "CONSENT TO MEDICAL CARE" BY COMPLETING ANY AND ALL ONLINE FORMS NECESSARY, IF ANY, UNDER "PATIENT REGISTRATION" AND FAXING OR EMAILING IT/THEM ALONG WITH YOUR STATE ISSUED PHOTO IDENTIFICATION AND ALL PERTINENT MEDICAL RECORDS WHICH IS AFFIRMATION AND AGREEMENT (CONTAINING YOUR SIGNATURE) AS CONSTITUTING A BINDING AGREEMENT BETWEEN Dr. Jeudy AND YOURSELF. YOU AGREE TO SEEK AND CONSULT WITH ONLY ONE, (1) PHYSICIAN AND/OR CLINIC, TREATMENT CENTER, HOSPITAL, REFERRAL SERVICE, CONSULTATION SERVICE OR ANY OTHER SERVICE OR BUSINESS FOR THE TREATMENT OF PAIN OR COMPLAINT FOR WHICH YOU ARE SEEKING TREATMENT WITH Dr. Jeudy. YOU FURTHER AGREE NOT TO SEE ANY OTHER PHYSICIAN, DOCTOR, PHYSICIAN’S ASSISTANT, OR NURSE PRACTITIONER WITHOUT PRIOR CONSENT OF THE ASSIGNED PHYSICIAN OR CLINIC OR SERVICE. YOU UNDERSTAND AND AGREE THAT IF YOU VIOLATE ANY PART OF THIS AGREEMENT YOUR SERVICES WILL BE REVOKED AND YOUR MEMBERSHIP TERMINATED FROM Dr. Jeudy. YOU FURTHER AGREE TO DOCUMENT AND MAKE KNOWN AN HONEST AND ACCURATE AND COMPLETE MEDICAL HISTORY, PAST TREATMENTS OF ANY AND ALL TYPES AND YOUR REACTION/RESPONSES TO PAST TREATMENTS. ANY DEVIATION FROM YOUR MEDICAL HISTORY OR PHYSICAL EXAMINATION FROM ANY PREVIOUS PHYSICIAN WHETHER WRITTEN OR VERBAL IS GROUNDS FOR IMMEDIATE DISMISSAL FROM Dr. Jeudy AND THE TREATING ORGANIZATION. YOU UNDERSTAND AND AGREE NOT TO REQUEST ANY EARLY REFILLS OF MEDICATION AND THAT THEY WILL NOT BE GIVE UNDER ANY CIRCUMSTANCES. YOU FURTHER AGREE TO USE ONLY ONE PHARMACY AND THAT YOU WILL NOT UNDER ANY CIRCUMSTANCE ATTEMPT TO OBTAIN PRESCRIBED MEDICATIONS FROM MORE THAN ONE PHARMACY. DOING SO IS GROUNDS FOR IMMEDIATE DISMISSAL FROM Dr. Jeudy AND THE TREATING ORGANIZATION. YOU AGREE AND UNDERSTAND THAT YOUR TREATING PHYSICIAN MAY ELECT AT ANY TIME DURING THE COURSE OF YOUR TREATMENT TO REQUEST THAT YOU UNDERGO A URINE TOXICOLOGY, (“UT”) TEST AND THAT THESE UT’S MAY BE ADMINISTERED AND REQUESTED AT RANDOM AND SHALL BE USED TO DETERMINE THE USE OF PRESCRIBED MEDICATIONS FOR THE TREATMENT OF PAIN. YOU AGREE AND UNDERSTAND THAT Dr. Jeudy AND/OR THE TREATING PHYSICIAN MAY AUDIT YOUR RECORDS OF MEDIAL HISTORY TO DETERMINE AUTHENTICITY AND TO VERIFY ANY INCONSISTENCIES OR ILLEGIBLE COPIES OR FACSIMILES.
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