Telemedicine Data Privacy Consent Form

Patient Details

Full Name Date of Birth Contact Number

Information

This form is intended to inform you about how your personal and medical information will be collected, used, stored, and protected during your participation in telemedicine consultations.

Consent

I have read and understood the above information and consent to the collection, use, and sharing of my data for telemedicine services.

Additional Notes or Questions

Patient Signature

Date

Provider/Witness Signature

Date