Medical Consent Form

Medical Consent Form
Name*

First NameLast Name
I, the undersigned, hereby consent to engage in
telehealthservices provided by Health Hero’s. I understand that
telehealthinvolves the use of electronic communications to
enable healthcare providers to deliver services to patients
remotely . I understand that the telehealth services may
include, but arenot limited to:

Video consultations, Audio consultations, Secure messaging, Electronic transmission of healthinformation
Benefits and Risks:

I have been informed of the potential benefits and risks associated with telehealth services. I understand that telehealth can offer convenience and flexibility but may have limitations compared to in-person visits. Risks may include, but are not limited to, technical failures, security breaches, and limitations in the ability to perform a physical examination.
Confidentiality:

I acknowledge that the telehealth services will be conducted in a private and secure manner, and my confidentiality will be protected in accordance with applicable laws and regulations
Provider-Patient Relationship:

I acknowledge that the telehealth services will be conducted in a private and secure manner, and my confidentiality will be protected in accordance with applicable laws and regulations
Emergency Situations:

I understand that telehealth services may not be appropriate for emergency situations. In case of an emergency, I will contact emergency services immediately
Cancellation and Rescheduling:

I understand the cancellation and rescheduling policies of the Telehealth Service Provider, and I agree to adhere to these policies.
Payment and Insurance:

I understand that I am responsible for any fees associated with the telehealth session and that payment will be processed according to the provider's policies. I also understand that insurance coverage for telehealth services may vary and that I am responsible for verifying my coverage with my insurance provider
Patient Consent:

I have read and understood the information provided in this Telehealth Medical Consent Form. I have had the opportunity to ask questions and my questions have been answered to my satisfaction. By signing below, I voluntarily consent to participate in the telehealth session.
Signature*

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Date*

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Medical Consent Form

Benefits and Risks:

Confidentiality:

Provider-Patient Relationship:

Emergency Situations:

Cancellation and Rescheduling:

Payment and Insurance:

Patient Consent: