Telehealth Consultation Consent Form for Colorectal Surgery

Patient Information

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

Nature of Telehealth Services

I understand that telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. For colorectal surgery consultations, telehealth may include:

• Pre-operative evaluation and assessment
• Post-operative follow-up care
• Review of diagnostic imaging and laboratory results
• Discussion of treatment options

Benefits and Limitations

• Benefits: Improved access to care, reduced travel time, convenience
• Limitations: Physical examination constraints, potential technical difficulties

Consent and Understanding

By signing this form, I understand and agree that:

1. The laws that protect privacy and confidentiality of medical information also apply to telehealth
2. I have the right to withhold or withdraw my consent at any time
3. While rare, security protocols could fail, causing a breach of privacy
4. In case of technical failure, an alternative method of care will be arranged
5. My healthcare provider may determine that telehealth is not appropriate and request an in-person visit

Emergency Protocol

In the event of an emergency during the telehealth consultation, my care will be directed to:

Nearest Emergency Department: _______________________________ Emergency Contact: ________________________________________

Signatures

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

Practice Information

[Practice Name] [Address] [Contact Information]