Telemedicine Consent Form

Patient Information

Full Name
Phone Number

Consent Information

I consent to engaging in telemedicine with my healthcare provider. I understand that telemedicine involves the use of electronic communications to enable healthcare services at a distance.

• I understand the possible risks and benefits of telemedicine as explained to me.
• I have the right to withdraw consent to telemedicine at any time.
• I understand that my information will be kept confidential as required by law.

I have read and understood the information above, and I give my consent to participate in telemedicine consultations.

Signature

Patient Signature

Date