Telemedicine Communication Consent Form

Please read the following information regarding telemedicine services and indicate your consent below.

Purpose

Telemedicine involves the use of electronic communications to enable healthcare providers to deliver services at a distance. These communications may include health information, diagnosis, consultation, treatment, and education.

Risks and Benefits

• All technical limitations and occasional disruption or disconnection may affect quality.
• Confidentiality of your health information may be compromised in rare circumstances.
• Telemedicine may be an alternative to in-person care.

Your Rights

• You may withdraw consent for telemedicine at any time.
• All laws regarding confidentiality and access to your medical information apply to telemedicine.
• You have the right to ask questions about any procedures and receive full explanations of the findings and recommendations.

Consent

I have read and understand the above information. I consent to participate in telemedicine consultations.