• Informed Consent for Teletherapy

    (through Zoom)
  • 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. 

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