Geriatric Telemedicine Consent Form

This consent form provides information about telemedicine services for geriatric patients. Please read each section, and indicate your understanding and agreement.

1. Nature of Telemedicine

2. Risks and Benefits

3. Confidentiality

4. Rights

I have read and understand the information provided above. My questions have been answered.

I voluntarily consent to participate in telemedicine services.

Patient/Authorized Representative Signature

Date

Provider Signature

Date