Telemedicine Consultation Consent Form for Vascular Surgery

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record Number: __________ Date of Consent: ________________

Nature of Telemedicine Consultation

I understand that telemedicine involves using electronic communication to enable healthcare providers at different locations to share individual patient medical information for diagnosis, therapy, follow-up, and/or education.

Specific Understanding for Vascular Surgery

1. I understand that my vascular surgeon may:

   • Review my imaging studies and vascular tests remotely
   • Evaluate post-operative healing through video examination
   • Assess symptoms and signs of vascular conditions
   • Provide guidance on medication management

2. I acknowledge that:

   • Some conditions may require in-person examination
   • Emergency vascular conditions cannot be managed via telemedicine
   • Physical examination limitations exist in virtual consultations

Benefits & Risks

Benefits:

• Improved access to vascular care
• Reduced travel time and costs
• Convenient follow-up care

Risks:

• Technical failures or interruptions
• Limited physical examination capabilities
• Potential need for in-person follow-up

Patient Rights

I understand that I have the right to:

• Withhold or withdraw my consent at any time
• Request in-person consultation when necessary
• Access my medical records

Signatures

Patient Signature: _________________ Date: _________________ Provider Signature: ________________ Date: _________________

Emergency Protocol

In case of emergency during the telemedicine consultation, contact: Emergency Contact: ________________ Phone: ________________ Nearest Emergency Department: ______________________________