Telehealth Consultation Consent Form for General 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 to share individual patient medical information for the purpose of improving patient care delivery. I understand that telehealth consultations for general surgery may include:

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

Limitations and Risks

I understand that:

1. The consulting surgeon will not be able to perform a complete physical examination through telehealth
2. There are potential risks to using technology, including:
   • Technical difficulties or interruptions
   • Unauthorized access to confidential information
   • Limited ability to perform emergency interventions

Patient Responsibilities

I agree to:

• Be in a private, well-lit location during the consultation
• Have necessary equipment (camera, internet connection) ready
• Provide accurate and complete information about my medical history
• Promptly seek in-person care if my condition worsens

Emergency Protocol

In the event of a medical emergency during the telehealth consultation, I understand that I should:

1. Call 911 immediately
2. Contact my nearest emergency department
3. Notify my surgical team through appropriate channels

Consent

By signing below, I acknowledge that I have read and understand the above information and consent to receive surgical consultation services via telehealth.

Patient Signature: _________________ Date: _________________

Provider Signature: ________________ Date: _________________

Contact Information

Surgical Practice: _________________ Emergency Contact: _______________ Phone: __________________________