Women's Health Telehealth Consent Form

This form is intended to obtain your consent to participate in telehealth services provided by your women’s health provider. Please read the information carefully.

Telehealth Description

Telehealth involves the use of electronic communications to enable healthcare providers to consult, diagnose, treat, and educate patients remotely.

Potential Benefits

• Increased access to women's health care services.
• Convenience of receiving care remotely.
• Continuity of care with your provider when in-person visits are not possible.

Potential Risks

• Technological failures might interrupt sessions.
• Security protocols may fail, resulting in possible breaches of privacy of medical information.
• Telehealth may not be appropriate for all clinical conditions.

Patient Rights

• You may withdraw consent at any time without affecting your right to future care.
• You have the right to ask questions and request clarification of procedures and technology used.
• All confidentiality protections afforded by law apply to telehealth.

Consent Acknowledgement

Please review and check each statement to acknowledge your understanding:

I have read and understood the information above regarding telehealth services. I understand the possible risks and benefits of participating in telehealth sessions. I have had the opportunity to ask questions and have received answers to my satisfaction. I voluntarily consent to participate in telehealth for my women's health care.