Patient Telehealth Privacy Consent

This form provides information to help you understand the benefits and risks of participating in telehealth services and to obtain your consent for telehealth consultations.

Telehealth Information

• Telehealth involves the use of electronic communications to enable healthcare services remotely.
• Your healthcare provider will discuss the diagnosis and treatment using audio, video, or other technology.
• Your privacy and confidentiality will be maintained in accordance with applicable laws and regulations.

Risks and Benefits

• Potential risks may include interruptions, unauthorized access, or technical difficulties.
• All reasonable measures will be taken to protect your information.
• Participation is voluntary, and you may withdraw consent at any time.

Patient Acknowledgement & Consent

By signing below, you acknowledge you have read and understood the information provided above, and you consent to participate in telehealth services.