Neurosurgical Telemedicine Consultation Informed Consent

Patient Information

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

Nature of Telemedicine Consultation

I understand that telemedicine involves the use of electronic communications to enable healthcare providers to share individual patient medical information for the purpose of improving patient care delivery. I understand that my neurosurgical provider will be at a different location from me.

Expected Benefits

• Improved access to neurosurgical care
• More efficient medical evaluation and management
• Reduced travel time and related costs

Potential Risks

1. Information transmitted may not be sufficient for proper clinical decision-making
2. Technical failures could result in information loss or consultation delays
3. In rare cases, security protocols could fail, causing a breach of privacy
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
• I may need to be seen in person if the neurosurgeon determines that telemedicine is not adequate
• In case of emergency, I must call 911 or go to the nearest emergency department

Consent

I have read and understand the information provided above regarding telemedicine. I hereby authorize [Practice Name] to use telemedicine in the course of my diagnosis and treatment.

Patient Signature: _________________ Date: _________________

Witness Signature: _________________ Date: _________________

Provider Signature: ________________ Date: _________________