Telehealth Consent Form
Telehealth Consultations: Telehealth technology allows healthcare providers to examine the patient with interactive videoconferences. Healthcare professionals, physicians, and therapists can remotely provide necessary services with this technology.
Purpose: The purpose of this form is to obtain your consent to participate in a telehealth visit in connection with PeriSteam Atlanta to discuss evaluation of Intake and Screening Form and present Personalized Course of Treatment Plan.
Confidentiality and Security: All information given at your telehealth visit will be kept and protected in full compliance with federal and state privacy laws. Efforts, including training of staff, using of secured platforms, updating/patching of software, and encryption of data, etc. have been made to keep your information confidential. No system is flawless. You agree that technological failures may occur. Some or all of your information may be electronically lost or breached. The telehealth visit may also be interrupted or cancelled due to technical failure(s).
Patient Rights: The patient can withhold or withdraw the telehealth consent at any time and this will not affect future treatment. The patient can ask questions regarding the consent, telehealth services and procedures for clarification.
Risks & Benefits: The patient has been informed about the potential risks and benefits of the telehealth service. You have had a chance to ask questions about the telehealth visit. You have received satisfactory answers to your questions.
Medical Records: All federal and state laws about access to your medical records apply to telehealth. You may request access to your medical records.
Services: Professionals and practitioners will schedule and conduct the treatment process. Patients accept to pay one-time Dream Wellness Consultation fees when applicable.