Telemedicine Consultation Consent Form for Plastic Surgery

Patient Information

Name: _______________________________ Date of Birth: ________________________ Date: ________________________________

Consent for Telemedicine Services

I, _________________________, hereby consent to participate in telemedicine consultations with Dr. _________________________ and [Practice Name] for my plastic surgery care.

Understanding of Telemedicine Services

1. I understand that telemedicine involves:

   • The use of electronic communications to enable healthcare providers to share individual patient medical information
   • Live two-way audio and video interactions
   • Electronic transmission of medical records and images

2. I acknowledge that:

   • My healthcare provider has explained how telemedicine works
   • Online consultations are not the same as direct in-person consultations
   • There are potential risks, including technical difficulties and limited physical examination capabilities

Limitations and Risks

• I understand that telemedicine consultations are appropriate for initial evaluations and follow-up care but may not be suitable for all plastic surgery needs
• Physical examinations and certain procedures cannot be performed remotely
• Final surgical decisions may require in-person evaluation

Privacy and Security

1. I understand that:
   • Electronic systems used will incorporate network and software security protocols
   • Privacy measures will be implemented to protect my medical information
   • There is still a risk of privacy breach despite security measures

Patient Rights

I acknowledge that I have the right to:

• Withdraw this consent at any time
• Request in-person consultations instead of telemedicine services
• Access my medical records from the telemedicine consultation

Financial Responsibility

I understand that:

• Insurance coverage for telemedicine services may vary
• I am responsible for confirming coverage with my insurance provider
• Payment for uncovered services will be my responsibility

Signatures

Patient Signature: ___________________ Date: ___________

Provider Signature: __________________ Date: ___________

Witness: ___________________________ Date: ___________