Telehealth Consent

1. I understand that my health care provider wishes me to engage in a telemedicine consultation.
2. My health care provider has given me instructions on how the video conferencing technology will be used to conduct such a consultation. I understand that it is not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my primary health care provider. These individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence and will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
5. I have had the alternatives to a telemedicine consultation explained to me, and chose to participate in a telemedicine consultation. I understand that some parts of the exam involving physical and lab tests may be conducted by individuals at my location at the direction of the consulting health care provider.
6. I have been given the opportunity to ask questions of the health care provider regarding this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
By signing this form, I certify:
- That I have read or had this form read and/or had this form explained to me
- That I fully understand its contents including the risks and benefits of the procedure(s).
- That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
Confirmation*
- Yes, I Agree
Patient Information
Patient Email*
Patients Full Name*
Todays Date*
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