Cardiac Surgery Telehealth Consent Form

Patient Information

Name: _________________________ Date of Birth: __________________ Medical Record Number: _________

Consent for Telehealth Services

I, _________________________, consent to participate in telehealth consultations with my cardiac surgery care team at [FACILITY NAME].

Nature of Telehealth Services

• Pre-operative consultations
• Post-operative follow-up care
• Review of diagnostic test results
• Medication management
• Wound care assessment

Understanding and Agreements

1. Technology Requirements

   • Reliable internet connection
   • Device with video capability
   • Private, quiet location for consultation

2. Privacy and Security

   • The session will be conducted through HIPAA-compliant software
   • No recording of sessions without explicit written consent
   • Standard privacy practices apply to telehealth visits

3. Medical Emergency Protocol

   • In case of emergency during telehealth visit, care will be directed to: Emergency Contact: ________________ Phone: _________________________ Nearest Emergency Facility: ________

4. Limitations and Risks

   • Technology failures may interrupt service
   • Physical examination limitations
   • Possible need for in-person follow-up
   • Potential security risks inherent to electronic communication

Authorization

I understand that:

• I can decline telehealth services at any time
• My insurance coverage may vary for telehealth services
• I must report any changes in my condition promptly

Patient Signature: _________________ Date: _________ Provider Signature: ________________ Date: _________

Office Use Only

Consent Verified By: _______________ Date Entered: ____________________