Telepsychiatry Consent Form

Telepsychiatry Consent Form

PDO Kenya
Date of Birth

MonthDay Year
Date
TELEPSYCHIATRY/TELECOUNSELING CLIENT CONSENT PURPOSE: The purpose of "Telepsychiatry Consent Form" is to get the patient's consent in order to participate in appointments of telepsychiatry cares.

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

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

ACCESS: The client accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telepsychiatry appointment.

CLIENT RIGHTS: The CLIENT can withdraw his/her consent at any time and can ask questions related to telepsychiatry appointments and technical requirements for telecommunication.
Client Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Guardian Name

First Name Last Name
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 can withdraw the consent at any time, which will not affect my future treatment procedures. I understand that I can be charged fees for this service. I accept that I authorize health care professionals and use telepsychiatry for my treatment and diagnosis.
Date

MonthDay Year
Date
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