Telehealth Palliative Care Consent Form

Patient Information

Full Name Date of Birth Address Phone Email

Consent to Telehealth Services

I understand that palliative care services will be provided to me through telehealth, which involves the use of electronic communications to enable healthcare providers to consult and deliver care. I understand I have the right to withdraw my consent at any time.

Risks & Benefits

• I understand the possible benefits and limitations of telehealth.
• I understand the potential risk of unauthorized access to my information.

Confidentiality

I understand that all information shared will be kept confidential to the extent allowed by law.

Patient Acknowledgement & Signature

I acknowledge that I have read and understood this form: Signature Date