Informed Consent
INFORMED CONSENT
FOR MEDICAL ATTENTION
TELEMEDICINE
1) IDENTIFICATION OF THE HEALTH SERVICE PROVIDER.
This consent is granted in favor of CURA VIDA CLINICS COSTA RICA LLC SOCIEDAD DE RESPONSABILIDAD LIMITADA, a company holding the legal entity identification number: 3-102-877646, duly registered in the Registry of Legal Entities of Costa Rica, in volume 2023, entry 333699, a company that is dedicated to the provision of health services exclusively as a medical consultation and wellness center through legal access to medicinal cannabis, hereinafter referred to as "CURA VIDA CLINICS".
2) NATURE OF THE TELEMEDICINE SERVICE.
Telemedicine is a form of healthcare delivery that takes place remotely, using telecommunications technologies such as videoconferencing or telephone. This allows for clinical evaluation, preliminary diagnosis, medical prescription (when appropriate), and follow-up.
a) It involves the use of audio, video, and other electronic communications to interact with you, consult with other professionals about your care, and/or review your health information for the purpose of making a diagnosis, providing treatment, monitoring services, and/or education.
b) The electronic systems used incorporate security protocols (rules) to protect the confidentiality of data and images, as well as to protect and guarantee their integrity, preventing the misuse of their information.
c) During your care, you and the treating professional will communicate through a computer, telephone, tablet or other electronic device that has a microphone and in some cases a camera, so that you can hear and eventually see each other.
d) You will need one of these devices in good working order, an internet connection or telephone line, and the necessary skills to use it. The information generated through any of these methods will be included in your health record.
3) LIMITATIONS OF TELEMEDICINE.
I understand that it does not completely replace in-person consultation, does not allow for a complete physical examination, may limit diagnostic accuracy, and may require subsequent in-person assessment.
4) ASSOCIATED RISKS.
I acknowledge the following risks:
Common risks:
Telemedicine has certain risks and limitations due to the use of technology, such as:
a) Technical problems related to failures in the internet network or with electronic devices (landline phones, computers, smartphones and tablets that you may use to communicate with the health professional treating you), which may delay your care.
b) Difficulty or fear of using electronic devices.
c) The quality of the images, photographs, or videos may not be adequate, so the health professional may recommend another appointment via telemedicine or an in-person consultation.
d) In telemedicine, the information received may not be sufficient, thus limiting the professional's ability to reach a diagnosis; in this situation, a face-to-face consultation could be recommended.
More serious risks.
The most serious risks that can arise as part of telemedicine care are:
a) The loss of your privacy, since there may be people in the home or at the place where you are, who could hear the conversation.
b) The loss of confidentiality, since it may be necessary to send images, photos or videos between you and the health professional; however, it should be clarified that CURA VIDA CLINICS safeguards and protects the information of every patient in a safe and responsible manner.
c) In exceptional cases, security protocols (rules) can fail, and cybercriminals could gain access to certain confidential data belonging to you.
Customized risks.
The professional will explain and note in observations your medical, psychological and social conditions, among others, that generate any additional risk for the telemedicine care that is proposed to you.
Information of interest.
It is important that you know that:
a) Every medical professional who participates in telemedicine is obliged to comply with the duty of confidentiality.
b) No information obtained through telemedicine will be disclosed to unauthorized third parties.
c) It is necessary that during the application of telemedicine you are in a place where privacy is respected and you are not interrupted.
d) You must inform the professional who will accompany you during the appointment.
e) The information obtained during the telemedicine consultation will be recorded by professionals in the health record and will be safeguarded by CURA VIDA CLINICS.
f) The care may be recorded if the professional gives their consent; this must be documented in the health record.
g) Occasionally, the presence of technical staff may be necessary to support remote transmission; in that case, you will be informed prior to the service.
h) If you require assistance during telemedicine care, you should consider the elements recommended by the health authorities regarding protective measures in case they are necessary.
i) If an urgent health problem arises during the care, you should ask for help, and your companions should call the 911 Emergency System or go to the nearest emergency service.
j) You have the right to refuse or revoke this consent at any time during care, without this affecting your right to future care or treatment.
5) CONFIDENTIALITY AND SECURITY.
CURA VIDA CLINICS is committed to maintaining the confidentiality of medical information, implementing reasonable security measures, and recording care in the medical record.
6) PROCESSING OF PERSONAL DATA.
In accordance with Law No. 8968, I authorize the processing of my personal data, including sensitive health data, for the provision of medical services, preparation of clinical records, monitoring of treatment and compliance with legal obligations.
The data processed includes full name, identification, contact details, and relevant medical information.
7) RIGHTS OF THE DATA SUBJECT.
I have been informed that I can exercise my rights of access, rectification, cancellation and opposition by sending a request to the email: robert@curavidacannabisclinics.com
8) PATIENT RIGHTS.
a) I declare that all the information I have provided about my health condition is true and that I have not omitted any aspect that I have been asked about.
b) Furthermore, I declare that I have been orally informed about everything related to the application of telemedicine and that there is the possibility of denying and/or revoking consent without affecting my other rights.
9) RECORDING OF TELEMEDICINE CARE.
I have been informed that telemedicine medical care may be recorded in audio and/or video format, exclusively for the purposes of:
a) Clinical documentation.
b) Continuity of treatment.
c) Improvement of service quality.
d) Compliance with legal or regulatory obligations.
I understand that:
a) The recording will be part of my medical record.
b) It will be treated as sensitive health data, under strict confidentiality and security measures.
c) It will not be disclosed to third parties without my consent, except where legally required.
d) I can revoke this authorization at any time, without affecting my right to receive medical care.
I have also been informed that I will not be able to make recordings on my own without the prior consent of the health professional, in order to protect the right to image and confidentiality of the parties.
INFORMED CONSENT
CURA VIDA CLINICS CVCC
The undersigned (referred to as the Client or Patient) freely, unequivocally, specifically, and knowingly AUTHORIZES CURA VIDA CLINICS COSTA RICA LLC SOCIEDAD DE RESPONSABILIDAD LIMITADA, a company holding legal entity identification number 3-102-877646, duly registered in the Registry of Legal Entities, Volume 2023, Entry 333699, a company dedicated exclusively to providing health services as a medical consultation and wellness center through legal access to medicinal cannabis in Costa Rica. It provides clinical evaluations, prescriptions, and continuous patient follow-up under Law No. 10113, the Law on Cannabis for Medicinal and Therapeutic Use and on Hemp for Food and Industrial Use, and its Regulations. hereinafter referred to as CURA VIDA CLINICS, to store the following data:
Types of data requested: Public personal data: Full name, identification number, gender, and marital status; Private personal data with restricted access: Email address, exact address, among others. Sensitive data: This includes information about health, ethnic origin, socioeconomic status, and other relevant factors.
CURA VIDA CLINICS recognizes, in accordance with Law No. 8986, "Law on the Protection of Individuals with Regard to the Processing of their Personal Data and its Regulations," the right to informational self-determination. Therefore, the personal information you provide must be truthful, accurate, and up-to-date, and you have the right to consult, modify, delete, and revoke it. You can do this by sending your request to the email address: robert@curavidacannabisclinics.com
The data you provide will be stored and protected in our database to monitor and track the services offered to you, for the purposes strictly related to CURA VIDA CLINICS, and is therefore for internal use, except in those cases and exceptions provided by law.
Therefore, I declare and acknowledge that:
a) There is a database called CURA VIDA DATABASE, which CURA VIDA CLINICS owns for the storage and processing of personal data, by virtue of the services it provides to its clients and patients.
b) That the collection of this personal data for its use, consultation, processing and treatment of personal data, throughout the service relationship.
c) That the answers to the questions asked of the Client during the data collection process are optional.
d) That personal data may be used by CURA VIDA CLINICS for the purposes of processing and providing services, as well as prospecting and offering other products and services, via any means of communication.
e) The recipients of the personal data, as well as the persons who may consult them, will be the administrative team of CURA VIDA CLINICS or external service providers for the analysis and processing of personal data, all of whom will be obliged to comply with the confidentiality and data protection policies of CURA VIDA CLINICS.
f) The treatment that CURA VIDA CLINICS will give to the requested personal data will be its analysis, to determine the provision of services to its clients, for exclusively internal purposes.
g) The Client has the right to provide or not provide the data requested by CURA VIDA CLINICS, therefore the Client is not obliged in any case to provide personal information, however, the only consequence of not providing us with the requested data will be the partial provision of the services, this because the information requested is strictly necessary and not excessive, strictly adhering to the principle of data quality of the regulation in the matter.
h) Pursuant to Law No. 8968, the Client has a series of rights regarding the personal information provided to CURA VIDA CLINICS, such as the right to request the rectification, updating, or deletion of said information, which will always remain the property of the Client. These rights may be exercised via email at robert@curavidacannabisclinics.com and at the company's physical address, located in San José, San Antonio de Escazu, de CG Pilates casa diagonal blanca.
i) The person responsible for the database will be Mr. Robert Callaghan, who can be contacted at the email address robert@curavidacannabisclinics.com
j) CURA VIDA CLINICS, when and for the effective provision of the services requested or offered, may collect, verify and consult the Client's personal data, existing in other databases provided by third parties.
k) CURA VIDA CLINICS may assign, transfer, and exchange the personal data it obtains and maintains in its database internally and with third parties, located outside the internal scope, that provide or will provide services to CURA VIDA CLINICS, such as: the Ministry of Health of Costa Rica, authorized dispensing pharmacies, external providers of medical software services and/or data hosting or storage; with the understanding that such information will not be sold or otherwise commercialized, the foregoing for the effective provision of the services requested or offered by CURA VIDA CLINICS.
This Informed Consent is electronic; therefore, the Client declares that they have the legal capacity to be bound by and accept the foregoing clauses, terms and conditions, which they have read in their entirety, understand, and accept without restrictions or reservations.
Acceptance of this Consent is carried out through a verifiable electronic mechanism in accordance with Law No. 8454 and its Regulations.
Acceptance by "click" or biometric authentication constitutes an unequivocal manifestation of the Client's will and will have the same validity as a handwritten signature.
X. SIGNATURES AND ACCEPTANCE.
In light of the above:
☐ I AUTHORIZE the recording of the telemedicine consultation.
I freely and voluntarily complete the following information:
☐ I agree to receive medical care via telemedicine.
By signing this document, I give my informed consent to CURA VIDA CLINICS to keep my data in its Database in accordance with what has been informed to me herein.