TELEHEALTH CONSENT FORM

TELEHEALTH CONSENT FORM

Michele Sallean, LCSW, PA
TELEHEALTH PATIENT CONSENT

PURPOSE: The purpose of this form is to obtain patient consent to participate in a telehealth session for behavioral and therapeutic services. Telehealth communications, including video and audio, will not be recorded. Notes will be taken by therapist to provide continuity of care.

MEDICAL INFORMATION: The information given by the patient for purposes of treatment will be discussed during the telemedicine appointment using video and audio.

ACCESS: The patient accepts that he/she needs access to a PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment.

PATIENT RIGHTS: The patient can withdraw his/her consent at any time. Any questions related to telemedicine appointments or technical requirements for telecommunication will be addressed throughout the full duration of treatment.
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Guardian Name if a Minor

First Name Last Name
By signing this form,

I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures.

I accept that I authorize Michele Sallean, LCSW to use telemedicine for my treatment and diagnosis.
Date *

Month Day Year
Date
Signature *

Clear
Should be Empty: