Telehealth Informed Consent for Minors

This form is to obtain your consent to participate in telehealth services for minors. Please read and sign below.

1. Telehealth Overview

Telehealth uses electronic systems to provide health care services remotely. These sessions may be conducted through video, audio, or other electronic communications.

2. Confidentiality

All information shared through telehealth is confidential, except in situations required by law.

3. Risks and Benefits

Benefits: Expanded access to care, convenience.
Risks: Technology failure or privacy/security limitations.

4. Parent/Guardian Consent

A parent or legal guardian must provide consent for minors to participate in telehealth services.

5. Right to Withdraw

You may withdraw consent for telehealth services at any time.

6. Acknowledgment

I have read and understand the information provided above. I voluntarily consent to telehealth services for the minor named below.

Minor's Full Name:

Minor's Date of Birth:

Parent/Guardian Name:

Relationship to Minor:

Parent/Guardian Signature:

Date:

Additional Comments or Questions: