Telemedicine Consent Form

Jersey Medical Weight Loss Center
TELEMEDICINE PATIENT CONSENT

PURPOSE: The "Telemedicine Consent Form" is to get the patient's consent in order to participate in Telemedicine service.

TELEMEDICINE INFORMATION: Telemedicine involves the practice of healthcare delivery, diagnosis,consultation,treatment, transfer of medical data and education using interactive audio, video and data communication. Telemedicine-based visits may not be as complete as face-to-face encounters. Hence the benefit cannot be guaranteed or assured.

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

Privacy: Televisits are done through a secure, HIPAA compliant platform.
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'm financially responsible if not covered by my insurance or if I do not have medical insurance coverage.

I authorize my physician to use telemedicine for the consultation.
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Name*

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Date*

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