Telehealth Consent Form

Yona Edda Aris Health LLC - Telehealth Consent Form
Patient Name
Date of Birth

MonthDayYear
Date
Date

MonthDayYear
Date
Purpose of This Form: This form is intended to inform you about the nature of telehealth services provided by Yona Edda Aris Health LLC and to obtain your informed consent to receive healthcare via telehealth.

Telehealth is the delivery of healthcare services using interactive audio, video, or other electronic communication. It allows you to consult with your provider remotely, without being in the same location.

Convenient access to care from your home

Faster scheduling and reduced travel time

Improved access to specialists or primary care providers

Technical failures (e.g., poor video connection)

Security/privacy breaches despite HIPAA-compliant systems

Incomplete assessment due to lack of physical examination
You may withhold or withdraw consent at any time.

You have the right to ask questions about any procedure or treatment.

You may request in-person care if available and appropriate.

My healthcare provider will determine if telehealth is appropriate for my care.

I may be asked to verify my identity before the visit.

The visit will not be recorded.

My information is protected and kept confidential as required by HIPAA.
By signing below I give my voluntary consent to receive telehealth services from Yona Edda Aris Health LLC
Signature of Patient or Guardian

Clear
Date

MonthDayYear
Date
Should be Empty: