Telehealth Patient Consent Form

Telehealth Patient Consent Form
Consultation Procedure
- During the Telehealth consultation, your medical history, examinations and results can be discussed with other health professionals.
- A physical examination on you may take place.
- During the procedure, video, audio or photo record of you can be taken.
- A Student Nurse Practitioner or Certified Medical Assistant may be in the room during consultation.
- In case of any technical problem or if translation services are needed, a non-medical technician may be in the room during consultation.
Medical History and Records

The Telehealth consultation have been protected by the law regarding your medical history and records. The telecommunications between you and your health care professional can be recorded. If any record is taken, it will not be shared without your consent.

Confidentiality

In case of any confidentiality risk, all the reasonable and appropriate efforts have been made under the federal law.

Rights

You can always take your grant back and withdraw your consent back at any time.

All the procedures, potential risks, consequences and benefits have been told to you by your health care professional. And you have given an opportunity to ask your concerns and questions which have been answered.
Patient Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Date of Birth

MonthDayYear
Date
Social Security Number
(Optional)
I sign this consent form on the behalf of:

MyselfMy familySomeone as a legal guardian
Your Name

First NameLast Name
What is your relationship with this person?
Phone Number

Area CodePhone Number
Email
example@example.com
Date of Sign

MonthDayYear
Date
Signature

Clear
Health Care Professional Name

Kamala Foster, MD
Signature

Clear
Should be Empty: