Telemedicine Informed Consent Form
Patient Information
Patient Full Name
Date of Birth
Email Address
Phone Number
Consent to Telemedicine
I understand the risks and benefits of telemedicine.
I consent to receive health services via telemedicine.
Confidentiality
I understand that my privacy will be protected during telemedicine sessions.
Patient Rights
I have the right to withdraw consent at any time.
Questions or Concerns
List any questions or concerns:
Signature
Patient Signature
Date