Orthopedic Telemedicine Consultation Informed Consent

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record Number: __________ Date: _____________________

Nature of Telemedicine Services

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. I understand that telemedicine consultations for orthopedic care may have limitations compared to in-person visits.

Understanding and Agreement

1. I understand that:

   • My orthopedic healthcare provider will be at a different location from me
   • Video, audio, and/or photo recordings may be taken during the session
   • A physical examination may be conducted through video observation
   • There are potential risks to technology, including service interruptions and unauthorized access

2. Expected Benefits:

   • Improved access to orthopedic care
   • More efficient medical evaluation and management
   • Obtaining expertise of a distant specialist

3. Potential Risks:

   • Information transmitted may not be sufficient to allow for appropriate medical decision making
   • Delays in medical evaluation and treatment could occur due to technical failures
   • Security protocols could fail, causing a breach of privacy
   • Lack of access to complete medical records may result in adverse drug interactions or allergic reactions

Medical Emergency Procedures

In the event of a medical emergency during the telemedicine consultation:

• Emergency Contact Name: _______________________
• Emergency Contact Phone: ______________________
• Nearest Emergency Department: __________________

Patient Rights

I understand that I have the right to:

• Withhold or withdraw consent at any time
• Access my medical information and records
• Receive in-person care at any time by terminating telemedicine services

Signatures

Patient Signature: _________________________ Date: __________ Provider Signature: ________________________ Date: __________

Office Use Only

Consent Reviewed By: ______________________ Date: __________ Telemedicine Platform Used: ________________ Time: __________