Telemedicine Consultation Consent Form for Dermatology Services

Patient Information

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

Nature of Telemedicine Services

I understand that telemedicine involves the use of electronic communications (video, audio, and/or photo sharing) to enable healthcare providers to evaluate, diagnose, and treat dermatological conditions remotely.

Consent and Understanding

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

1. Technology Requirements

   • I need reliable internet access
   • I must use a secure device with video/photo capabilities
   • I am responsible for ensuring privacy at my location

2. Benefits and Limitations

   • Improved access to dermatological care
   • Reduced travel and waiting time
   • Some conditions may require in-person examination
   • Image quality may affect diagnosis accuracy

3. Security and Privacy

   • Sessions are not recorded without explicit consent
   • HIPAA-compliant platforms are used
   • Standard privacy protections apply

4. Emergency Situations

   • Telemedicine is not suitable for emergencies
   • I will seek emergency care if needed
   • Alternative care facilities have been identified

Financial Responsibility

I understand that:

• Insurance coverage for teledermatology may vary
• I am responsible for any uncovered costs
• Cancellation policies still apply

Signature

Patient/Guardian Signature: _________________ Date: __________ Provider Signature: _______________________ Date: __________

Form Version: [Date] Practice Name: _________________________