Neurology Telemedicine Informed Consent Form

Patient Information

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

Nature of Telemedicine Services

I understand that telemedicine involves using electronic communications to enable healthcare providers to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up, and/or education.

Expected Benefits

• Improved access to neurological care
• More efficient medical evaluation and management
• Reduced travel time and related costs
• Reduced exposure to infectious diseases

Potential Risks

1. Information transmitted may not be sufficient to allow for appropriate medical decision-making
2. Technical failures could result in loss of information or delays in medical evaluation/treatment
3. Security protocols could fail, causing a breach of privacy of personal medical information
4. Limited physical examination capabilities

Understanding and Agreement

By signing this form, I understand and agree that:

• Laws that protect privacy and medical information also apply to telemedicine
• I have the right to withhold or withdraw my consent at any time
• In case of emergency, this service may not be appropriate and in-person care may be required
• I may need to be seen in person if the neurologist determines that telemedicine is not adequate

Emergency Protocol

In case of emergency during a telemedicine session, my care will be directed to: Emergency Contact: _________________ Phone: ____________________ Nearest Emergency Department: _________________________________

Consent

I have read and understand the information provided above regarding telemedicine. I hereby authorize Dr. _________________ to use telemedicine in the course of my diagnosis and treatment.

Patient Signature: _________________ Date: _____________________ Witness Signature: _________________ Date: _____________________

Provider Documentation

I have explained the contents of this document to the patient and have answered all questions.

Provider Signature: ________________ Date: _____________________