Pediatric Telemedicine Informed Consent Form

Patient Information

Child's Name: _________________________ Date of Birth: _____________ Parent/Legal Guardian Name: ______________________________________

Consent for Telemedicine Services

Nature of Telemedicine

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 pediatric care
• More efficient medical evaluation and management
• Obtaining expertise of specialists when needed

Possible Risks

I understand that while telemedicine has potential benefits, there are also potential risks including:

• Technical difficulties or equipment failures
• Information security breaches despite security measures
• Limited physical examination capabilities
• Need for in-person follow-up care

Rights and Responsibilities

1. I understand I can decline telemedicine services at any time
2. All existing confidentiality protections under federal and state law apply
3. I have access to all medical information transmitted during telemedicine visits
4. I understand insurance benefits may vary for telemedicine services

Emergency Protocols

In case of emergency during a telemedicine visit:

• Call 911 if immediate medical attention is needed
• Contact information for local emergency services: _________________
• Nearest emergency facility: ___________________________________

Authorization

I have read and understand the information provided above regarding telemedicine. I hereby authorize [PRACTICE NAME] to use telemedicine in the course of my child's diagnosis and treatment.

Signature: _________________________ Date: _______________ Relationship to Patient: _____________________________________