Telemedicine Consent Form

Jersey Medical Weight Loss Center/Aparna Medical Associates

1527,Route 27,Ste 2100,Somerset,NJ 08873
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.
Patient Name *

First Name Last Name
Date of Birth

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

Area Code Phone Number
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 accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.
Date

Month Day Year
Date
Signature *

Clear
Should be Empty: