Oncology Telehealth Consent Form

Patient Full Name

Date of Birth

Email Address

Phone Number

Telehealth Services

I understand that telehealth involves the use of electronic communications to enable healthcare providers at different locations to share my medical information for diagnosis, consultation, treatment, and education purposes.

Consent and Acknowledgements

I understand that laws that protect privacy and the confidentiality of my medical information also apply to telehealth.
I understand that my consent to participate in telehealth does not alter my rights regarding access to my medical information.
I acknowledge the possibility of risks associated with telehealth, including interruptions, unauthorized access, and technical difficulties.
I may withdraw my consent for telehealth at any time without affecting my right to future care or treatment.

Questions or comments

Patient Signature

Date