Telehealth Services Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

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.

Consent and Understanding

By signing this form, I understand and agree to the following:

1. Technology Requirements

   • I need access to reliable internet and appropriate devices
   • I am responsible for ensuring my technology meets minimum requirements
   • Technical difficulties may require rescheduling to in-person visits

2. Privacy and Security

   • While encrypted systems are used, no technology is 100% secure
   • Sessions will not be recorded without separate explicit consent
   • I will participate from a private, secure location

3. Medical Considerations

   • Some conditions require physical examination and cannot be treated virtually
   • Emergency situations require in-person emergency care
   • The provider may determine an in-person visit is necessary

4. Patient Rights

   • I can withdraw this consent at any time
   • I can ask questions about telehealth services
   • I retain all existing patient rights under applicable laws

Acknowledgment

I have read and understand the information provided above regarding telehealth services.

Patient Signature: _________________ Date: _________________

Provider Signature: ________________ Date: _________________

Office Use Only

Consent reviewed by: _______________ Date: _________________