Telehealth Informed Consent Agreement

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record Number: __________ Date: _________________________

Purpose and Nature of Telehealth Services

I understand that telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may include, but is not limited to:

• Live video consultations
• Secure messaging
• Remote monitoring of vital signs
• Electronic transmission of medical records

Benefits and Risks

Benefits:

• Improved access to medical care
• More efficient medical evaluation and management
• Reduced travel time and related costs

Risks:

• Technical difficulties may disrupt or delay the consultation
• Security protocols could fail, potentially compromising privacy
• Limited physical examination capabilities
• Medical conditions may require in-person evaluation

Patient Acknowledgments

By signing this form, I understand and agree that:

1. The laws that protect privacy and confidentiality of medical information apply to telehealth
2. I have the right to withhold or withdraw my consent at any time
3. I understand that all rules and regulations which apply to the practice of medicine in my state apply to telehealth
4. In case of an emergency, I must call 911 or go to the nearest emergency room

Signatures

Patient Signature: _________________ Date: _________________ Provider Signature: ________________ Date: _________________

Contact Information

Practice Name: ___________________ Phone: __________________________ Email: __________________________