Telehealth Appointment Online Consent Form

Telehealth Appointment Online Consent Form
Patient information
Name*

First NameLast Name
Email*
example@example.com
Phone number*
Please enter a valid phone number.
Date of birth*

DayMonthYear
Date
Appointment information

Details of the telehealth consultation to be claimed with Medicare.
Date of consultation*

DayMonthYear
Date
Time of consultation*

Hour Minutes

AM/PM Option
Health professional's name

First NameLast Name
Health professional's name*
Item number & Benefit amount can be billed depend on consultation from below table.
Agreement*

Yes, I agree to the assignment of the Medicare benefit directly to the health professional.
I am the:*

PatientParent or guardian of the patient
Name of parent or guardian

First NameLast Name
Relationship to the patient
Mother, father, carer, etc.
Signature*

Clear
Privacy note: Your personal information is protected by law, including the Privacy Act 1988, and is collected by Services Australia for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the agency or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations). You can get more information about the way in which the agency will manage your personal information, including our privacy policy.

Technical Guidelines and Expectations

I acknowledge that while using online/telehealth services, there might be unforeseen technical disruptions. Despite the best efforts from my healthcare provider(s), there's a chance that my information could be interrupted or misrepresented due to technical glitches.

Should any connection issues arise during our online/telehealth session, I am aware that my provider(s) will attempt to reach me by phone to resume our consultation.

I am responsible for ensuring I have the appropriate computer hardware, communication tools, and internet connectivity for my telehealth sessions. Additionally, it is my duty to secure a well-lit and private setting, devoid of interruptions, for these sessions.

Appropriate Consultation Setting

For an effective consultation, it's essential that I am situated in a serene and private indoor environment. While the session is ongoing, I must refrain from driving or partaking in other distracting activities.
Should be Empty:

Telehealth Appointment Online Consent Form

Patient information

Appointment information