Telehealth Informed Consent for Chiropractic Services

Patient Information

Name: _________________________ Date of Birth: _________________ Address: _______________________ Phone: ________________________

Nature of Telehealth Services

I understand that telehealth involves the delivery of chiropractic services using electronic communications, information technology, or other means between my chiropractor and me when we are not in the same physical location.

Anticipated Benefits

• Improved access to chiropractic care
• More convenient delivery of services
• Continuity of care during circumstances that prevent in-person visits

Potential Risks

I understand that potential risks of telehealth include:

• Technical difficulties or equipment failures
• Limited physical examination capabilities
• Potential need for in-person follow-up
• Information security risks despite best practices

Patient Responsibilities

I agree to:

1. Provide accurate contact information
2. Be in a private, well-lit location during sessions
3. Have adequate internet connectivity
4. Inform the chiropractor if anyone else is present
5. Not record sessions without prior consent

Emergency Protocols

In case of emergency during a telehealth session, my emergency contact is: Name: _________________________ Phone: ________________________

Consent

I have read and understand the information provided above regarding telehealth services. I hereby give my informed consent for the use of telehealth in my chiropractic care.

Patient Signature: _______________ Date: ________________________

Chiropractor Signature: __________ Date: ________________________

License Number: ________________