hgwELDERS.Org Telemedicine Consent Form
HGW Advocates HGW Medical Clinician
TELEMEDICINE PATIENT CONSENT
PURPOSE:
The purpose of "Telemedicine Consent Form" is to get the patient's consent in order to participate in appointments of telemedicine cares.
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 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 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 the questions related to telemedicine appointments and technical requirements for telecommunication.
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Type
Guardian Name
First Name
Last 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.
Date
-
Month
-
Day
Year
Date
Elder's Signature
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Submit
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