Telehealth Consent Form for Urgent Care Services

Patient Information

Name: _________________________ Date of Birth: _____________ Phone: _________________________ Email: ___________________

Consent for Telehealth Services

I, the undersigned patient, consent to participate in telehealth consultations with [CLINIC NAME] healthcare providers for my medical care.

Understanding of Telehealth Services

1. I understand that:
   • Telehealth involves real-time audio/video communication with healthcare providers
   • My provider will determine if telehealth is appropriate for my condition
   • Technical difficulties may necessitate rescheduling to in-person care
   • Medical information transmitted will be protected but no technology is 100% secure

Risks and Benefits

Benefits:

• Convenient access to medical care
• Reduced travel and wait times
• Minimized exposure to other illnesses

Risks:

• Technical/transmission problems
• Limited physical examination
• Possible need for in-person follow-up

Emergency Protocols

I acknowledge that telehealth is not suitable for emergencies. For emergencies, I will:

• Call 911 or
• Go to the nearest emergency department

Financial Responsibility

I understand that:

• Insurance coverage for telehealth services may vary
• I am responsible for any copays/coinsurance
• Cancellation policies apply as with in-person visits

Authorization

Patient Signature: _________________ Date: _______________

Guardian Signature: ________________ Date: _______________ (if applicable)

Provider Name: ____________________ Date: _______________