Informed Consent for Health

  1. I understand that my healthcare provider wishes to evaluate, diagnose, manage, and/or treat my medical condition through an interactive video communication involving the electronic transmission of information referred to as "telehealth" or "telemedicine." I further understand that because my provider and I are not in the same room, a telehealth consultation will not be the same as an in-person visit as my provider must rely solely on the information reported to make recommendations.
  2. I understand that while steps are taken to secure the telehealth communication, there is no guarantee of security and there are potential risks to this technology, including interruptions and disconnections of the audio/video link, unauthorized access, and other technical difficulties.
  3. I understand that my healthcare provider or I can discontinue the consultation at any time for any reason. I further understand that I can be seen in person at another time and confirm that my participation in telehealth is completely voluntary.
  4. I understand that while this telehealth session will not be recorded, it will be documented.
  5. By participating in a telehealth consultation, I confirm that the risks, benefits and any practical alternatives have been discussed, I have had the opportunity to ask questions regarding the process, and that my questions have been answered to my satisfaction

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