Cardiology Telehealth Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record Number: __________ Date: _________________________

Nature of Telehealth Services

I understand that telehealth involves the delivery of cardiovascular healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location.

Understanding and Agreements

1. Nature of Virtual Visit

   • I understand that my healthcare provider will not be physically present during the consultation
   • The visit will be conducted through secure video conferencing technology
   • My provider may recommend an in-person visit if needed

2. Medical Information and Records

   • All existing laws regarding medical records access and confidentiality apply
   • I have the right to withhold or withdraw consent at any time

3. Technology Requirements

   • A reliable internet connection is necessary
   • Access to a device with video and audio capabilities
   • Private location to conduct the visit

4. Risks and Benefits

   • Benefits include: convenience, reduced travel, continuity of care
   • Risks include: technology failures, limited physical examination, potential security risks

5. Emergency Protocols

   • In case of emergency during the telehealth visit, call 911
   • Emergency contact name: _________________ Phone: _______________

Consent

I have read and understand the information provided above regarding telehealth services, and all my questions have been answered to my satisfaction.

Patient Signature: _________________________ Date: _______________

Provider Name: ___________________________ Provider Signature: ________________________ Date: _______________