Telemedicine Informed Consent Form

TELEMEDICINE PATIENT CONSENT PURPOSE:

The purpose of this “Telemedicine Consent Form” is to get the patient’s consent in order to participate in appointments of telemedicine care. RECORDS: Telecommunications with patients will not be recorded and stored. Patients’ medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies.

TELEMEDICINE INFORMATION:

The medical information related to the history, records, and tests of the patient will be discussed during the telemedicine appointment with video and audio.

ACCESS:

The patient accepts that he/she needs access to a PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment.

PATIENT RIGHTS:

The patient can withdraw his/her consent at any time and can ask questions related to telemedicine appointments and technical requirements for telecommunication.

    Patient Name
    Guardian Name
    By signing this form, I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices. I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures. I understand that I can be charged the additional fees that my insurance does not cover. I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.
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