Telehealth Consent Form

Patient Information

Full Name Date of Birth Address

Telehealth Session Details

Healthcare Provider Name Date of Telehealth Session

Consent

I understand that telehealth involves the use of technology to allow communication, diagnosis, treatment, and education remotely between myself and my healthcare provider. I acknowledge the risks and limitations associated with telehealth, including potential interruptions, unauthorized access, and technical difficulties.

I consent to participate in telehealth sessions and authorize my provider to use telehealth for my care.

Patient Signature

Signature Date