Pre-Surgical Telehealth Consent Form
Patient Information
Full Name
Date of Birth
Email Address
Phone Number
Address
Surgical Procedure
Procedure Name
Scheduled Date
Telehealth Visit Details
Date of Telehealth Visit
Healthcare Provider
Consent Statements
I understand the purpose, benefits, and alternatives to the proposed surgical procedure have been explained to me.
I consent to discuss my pre-surgical assessment and instructions via telehealth.
I understand the limitations and risks of telehealth compared to in-person visits.
I acknowledge my privacy rights and the confidentiality of my medical records.
I have had the opportunity to ask questions regarding my care and telehealth visit.
Additional Comments
Patient's Signature
Date