Chronic Pain Telehealth Consent Form

Patient Information

Full Name Date of Birth Phone Number Email Address

Telehealth Services

Consent and Acknowledgement

• I understand the purpose and nature of telehealth consultations for chronic pain management.
• I understand the risks and benefits associated with telehealth services.
• I understand I may withdraw consent at any time.
• I am responsible for providing accurate information during telehealth sessions.
• I acknowledge all my questions have been answered regarding telehealth.

Signature

Signature (Type your full name) Date