Telehealth Services Consent Form for Endocrinology Care

Patient Information

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

Nature of Telehealth Services

I understand that telehealth involves the delivery of endocrinology 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.

Consent and Understanding

1. I understand that:

   • My endocrinologist will be at a different location from me
   • I have the right to withdraw this consent at any time
   • All existing confidentiality protections apply to telehealth consultations
   • I may need in-person visits for certain conditions or procedures

2. I acknowledge that:

   • Telehealth visits are not appropriate for medical emergencies
   • Technical difficulties may require rescheduling of the appointment
   • My healthcare information may be shared with other individuals for scheduling and billing

Specific Endocrine Care Considerations

• Laboratory tests and imaging studies must be completed before telehealth visits as requested
• Vital signs, including blood glucose readings, must be available during consultations
• Certain physical examinations cannot be performed via telehealth

Privacy and Security

I understand that while electronic systems incorporate network and software security protocols, the privacy and confidentiality risks inherent in electronic communications cannot be eliminated.

Patient Agreement

By signing below, I confirm that I have read and understand the information provided above regarding telehealth services.

Patient Signature: _________________ Date: __________________

Provider Signature: ________________ Date: __________________