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Telehealth Consent Form

Telehealth Consent Form

If you think you may be having a medical emergency, do not use this form. Dial 911 or your local emergency number. If you need help with this form call 302-832-1545, Monday through Friday 8am to 4pm.
10Questions
  • 1

    Permission for Telehealth Visits

    • This Telehealth Consent Form is required if you wish to use telehealth for online, telephone, and video consultations.
    • This Form requires your signature at the end to grant us telehealth permission.
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  • 2

    What is telehealth?

    Telemedicine involves the use of electronic communication technologies by a health care provider to deliver health care services to a patient when the patient and provider are at different locations.

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  • 3

    Benefits: Potential benefits of telemedicine include improved access to health care

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  • 4

    Risks:   I understand that there are potential risks associated with the use of technology for telemedicine services, including but not limited to:

     • The video connection may not work, or may stop working during the telemedicine visit;

     • The video or sound may not be clear enough to be useful to effectively complete the telemedicine visit;

     • I may need to reschedule an in-person visit if the health care provider believes the information able to be obtained during the telemedicine visit is not sufficient;

     • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;

     • Security protocols could fail, causing a breach of privacy of personal medical information.

     

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  • 5

    Do I have to sign this document?

    • No. Only sign this document if you want to use telehealth.
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  • 6

    What does it mean if I sign this document?

    If you sign this document, you agree that:

    • We talked about the information in this document.
    • We answered all your questions.
    • You want a telehealth visit.

     If you sign this document, we will give you a copy.

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  • 9
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  • 10
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