• Telehealth Consent Form

  • TELEHEALTH PATIENT CONSENT

    PURPOSE: The purpose of "Telehealth Consent Form" is to get the patient's consent in order to participate in appointments of telemedicine cares.

    RECORDS: Telecommunications with patients will not be recorded and stored. Patients' medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies.

    TELEHEALTH INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telehealth appointment with video and audio.

    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 telehealth appointment.

    PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telehealth appointments and technical requirements for telecommunication.

  • By signing this form,

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

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

    I understand that I can be charged the additional fees that my insurance does not cover.

    I accept that I authorize health care professionals and use telehealth for my treatment and diagnosis.

  •  -  -
    Pick a Date
  • Clear
  • Should be Empty:
Jotform Logo
Now create your own JotForm - It's free! Create your own JotForm