Informed Consent for Teletherapy

Patient's name *

First Name Last Name

CONSENT FOR TELEHEALTH CONSULTATION

1. I understand that my speech-language pathologist wishes me to engage in a
telehealth consultation.
2. My speech-language pathologist explained to me how the video conferencing
technology that will be used to affect such a consultation will work during
therapy sessions.
3. I understand that a telehealth consultation has potential benefits including
easier access to care and the convenience of meeting from a location of my
choosing.
4. I understand there are potential risks to this technology, including
interruptions, unauthorized access, and technical difficulties. I understand that
my health care provider or I can discontinue the telehealth consult/visit if it is
felt that the video conferencing connections are not adequate for the situation.
5. I have had a direct conversation with my provider, during which I had the
opportunity to ask questions in regard to this procedure. My questions have
been answered and the risks, benefits and any practical alternatives have been
discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY DOXY.ME

Doxy.me is a technology service we may use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in.
By signing this document, I acknowledge:
1. Doxy.me is NOT an Emergency Service and in the event of an emergency, I will
use a phone to call 911.
2. Though my provider and I may be in direct, virtual contact through the
Telehealth Service, neither Doxy.me or Simply Communication provides any
medical or healthcare services or advice including, but not limited to,
emergency or urgent medical services.
3. The Doxy.me Service facilitates videoconferencing and is not responsible for
the delivery of any healthcare, medical advice or care.
4. I do not assume that my provider has access to any or all of the technical
information in the Doxy.me Service – or that such information is current,
accurate or up-to-date. I will not rely on my health care provider to have any
of this information in the Doxy.me Service.
5. To maintain confidentiality, I will not share my telehealth appointment link with
anyone unauthorized to attend the appointment.

CONSENT TO USE THE TELEHEALTH BY ZOOM

ZOOM is a technology service we may use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in.
By signing this document, I acknowledge:
1. ZOOM is NOT an Emergency Service and in the event of an emergency, I will use a
phone to call 911.
2. Though my provider and I may be in direct, virtual contact through the Telehealth
Service, neither ZOOM or Simply Communication provides any medical or healthcare
services or advice including, but not limited to, emergency or urgent medical services.
3. The ZOOM Service facilitates video conferencing and is not responsible for the delivery
of any healthcare, medical advice or care.
4. I do not assume that my provider has access to any or all of the technical information
in the ZOOM Service – or that such information is current, accurate or up-to-
date. I will not rely on my health care provider to have any of this information
in the ZOOM Service.
5. To maintain confidentiality, I will not share my telehealth appointment link with anyone
unauthorized to attend the appointment.

By signing this form, I certify that I have read or had this form read and/or had this form explained to me. I certify that I fully understand its contents including the risks and benefits of the procedure(s). I certify that I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction. *

Agree

Signature *

Clear

Your name *

First Name Last Name

Relation to patient *

Today's date *

Date