Patient Telehealth Consent Form
We look forward to becoming your partner in your health care and understanding your health care
needs better.
Please review and sign the following consents PRIOR to your visit with us. We will ask you during the
initial visit if you had the opportunity to review the consents and allow you the opportunity to ask any
questions.
General Consent for Care and Treatment.
I have the right, as a patient, to be informed about my condition and the recommended surgical, medical
or diagnostic procedure to be used so that I may make the decision whether or not to undergo any
suggested treatment or procedure after knowing the risks and hazards involved. At this point in my care,
no specific treatment plan has been recommended. This acknowledge that this consent form is simply an
effort to obtain my permission to perform the evaluation necessary to identify the appropriate
treatment and/or procedure for any identified condition(s).
This consent provides permission for your office to perform reasonable and necessary medical
examinations, testing and treatment. By my verbal and signed consent, I am indicating that (1) I intend
that this consent is continuing in nature even after a specific diagnosis has been made and treatment
recommended; and (2) I consent to treatment at this office or any other satellite office under common
ownership. The consent will remain fully effective until it is revoked. I have the right at any time to
discontinue services.
I have the right to discuss the treatment plan with my provider about the purpose, potential risks and
benefits of any test ordered for me. If I have any concerns regarding any test or treatment recommend
by my health care provider, I am encouraged to ask questions. I voluntarily request a physician, and/or
mid-level provider (nurse practitioner, physician assistant, or clinical nurse specialist), and other health
care providers or the designees as deemed necessary, to perform reasonable and necessary medical
examination, testing and treatment for the condition which has brought me to seek care at this practice.
I understand that if additional testing, invasive or interventional procedures are recommended, I will be
asked to read and sign additional consent forms prior to the test(s) or procedure(s).
I certify that I have read and fully understand the above statements and consent fully and voluntarily to
its contents.
Consent to Treatment Using Telemedicine.
I consent to treatment involving the use of electronic communications to enable health care providers at
different locations to share my individual patient medical information for diagnosis, therapy, follow-up,
and/or education purposes. I consent to forwarding my information to a third party as needed to receive
telemedicine services, and I understand that existing confidentiality protections apply. I acknowledge
that while telemedicine can be used to provide improved access to medical care, as with any medical
procedure, there are potential risks and no results can be guaranteed or assured. These risks include, but
are not limited to: technical problems with the information transmission; equipment failures that could
result in lost information or delays in treatment. I understand that I have a right to withhold or withdraw
