Teledermatology Consent Form

Patient Information

Full Name: Date of Birth:

Introduction

You are being asked to participate in a teledermatology consultation. The purpose of this form is to obtain your consent for this service.

Information to be Shared

Medical records and images related to your skin condition may be shared with your dermatologist via electronic communication.

Consent

You understand that teledermatology involves the exchange of medical information electronically.
You can withdraw consent at any time without affecting your care.
There may be limitations due to the lack of physical examination.
Your privacy will be protected in accordance with applicable laws.

Patient Agreement

I have read and understood the information above and consent to the use of teledermatology services.

Signature: Date: