In accordance with California law, this Telehealth Informed Consent must be reviewed and acknowledged before participating in any telehealth wellness session with Regain Mens Pelvic Health. Print this page, sign it, and email it to [email protected] before your first class.
1. Nature of Telehealth Services
Regain Mens Pelvic Health provides online group wellness education classes via a HIPAA-compliant video platform (Zoom for Healthcare). These sessions focus on pelvic floor exercise education and incontinence management for men recovering from prostatectomy surgery. These are wellness education sessions — NOT individual physical therapy treatment — and do not constitute a formal patient-provider treatment relationship.
2. Technology Requirements
To participate, you will need a device with a working camera and microphone (smartphone, tablet, or computer), a stable internet connection, and a private comfortable space. Regain Mens Pelvic Health is not responsible for technical failures or equipment malfunctions on your end.
3. Privacy of Your Environment
You are responsible for ensuring your participation environment is private and that no unauthorized persons can view or hear your session. By participating, you confirm you have taken reasonable steps to protect your own privacy.
4. Risks and Limitations of Telehealth
Telehealth has limitations compared to in-person care, including: inability to physically assess your condition; potential technology interruptions; and limitations in observing exercise form from a distance. You understand and voluntarily accept these limitations.
⚠️ EMERGENCY PROTOCOL: Telehealth sessions are NOT appropriate for medical emergencies. If you experience chest pain, difficulty breathing, severe pain, a fall, or any medical emergency during a session — end the session immediately and call 911 or go to your nearest emergency room. Jongmoon Kwak cannot dispatch emergency services to your location.
5. Scope of Service
Jongmoon Kwak, PT, DPT, FAAOMPT, OCS provides wellness education only in this program. He is not acting as your treating physical therapist or physician. Specific medical questions or individual treatment needs should be directed to your personal healthcare provider or urologist.
6. Confidentiality
Sessions are NOT recorded without your explicit written consent. Your personal information is kept confidential in accordance with our Privacy Policy at regainmenspelvichealth.com/privacy-policy.html. Group session participants agree to respect the privacy of all other members.
7. Voluntary Participation & Right to Withdraw
Your participation is completely voluntary. In accordance with California Business and Professions Code Section 2290.5, you have the right to withhold or withdraw consent to telehealth services at any time without affecting your rights to future care or treatment. To withdraw, contact [email protected].
8. Acknowledgment
By signing below, I confirm that I have read and understood this Telehealth Informed Consent, had the opportunity to ask questions, and voluntarily consent to participate in telehealth wellness education sessions provided by Regain Mens Pelvic Health. I understand these are wellness education sessions and not individual medical treatment.