Telehealth Online Consent Form

Online Consent Form
Patient Information
Name*
Date of Birth*

MonthDayYear
Gender*
Email
example@example.com
Phone Number*
Format: (000) 000-0000.
Is this your First Time with us?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian or Emergency Contact Details
Contact Person Name*
Primary Phone Number*
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Medical Data
Are you currently interested in being treated for which of the following?
I am currently Pregnant/BreastfeedingUncontrolled DiabetesHospitalized in the past 30 daysPatient is under 4 years oldI have been told by a doctor that I have kidney diseaseI have been told by a doctor that I have a condition that makes it harder for your body to fight off infections? Or, are you taking any medicines that can weaken your immune system, like steroids or chemotherapy.I have been told by a doctor that I have an autoimmune disease.
Do you currently have a primary care doctor or clinic?*
Doctor/Clinic’s Name

First NameLast Name
Clinic’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have a drug allergy or Food allergy? *
Please let us know to which drug or food allergies you may have...
Acknowledgment, Authorization and Waiver
TELEHEALTH CONSENT FORM

TELEHEALTH SERVICES Telehealth involves the use of electronic information and communication technologies to deliver health care services to patients who are located at a different site than the provider. This includes, but is not limited to, video conferencing, audio communication, and text messaging.

POTENTIAL BENEFITS

· Increased accessibility to care

· Reduced wait times

· Convenience

POTENTIAL RISKS

· Limited physical examination

· Technical issues, such as connection problems

· Security breaches

CONSENT I understand the following:

· The laws protecting the confidentiality of medical information also apply to telehealth.

· I have the right to withhold or withdraw my consent to the use of telehealth services at any time.

· The care may not be as complete as a face-to-face service.

· I must take precautions to ensure the privacy of my environment during telehealth consultations.
I authorize the provider on duty from Bueno Clinic to perform any test, screening, and/or treatment to me/ or to my (for Parent/Guardian) dependent.I understand that if symptoms persist I must follow up with my primary care health care provider or clinic.I acknowledge that all information I provided in this form is true and accurate.I have read and understood the information provided regarding telehealth services, and all my questions have been answered to my satisfaction. I hereby give my informed consent to participate in telehealth consultations with the provider contracted by Bueno Clinic.
Date Signed

MonthDayYear
Patient/Parent/Guardian Signature*

Clear
Should be Empty:

Online Consent Form

Patient Information

Parent/Guardian or Emergency Contact Details

Medical Data

Acknowledgment, Authorization and Waiver