Telehealth Consent Form

Telehealth Consent Form

I wish to have a teleconsultation with Ascent Physical Therapy, PLLC ("The Practice). This means that I will, through interactive video connection, be able to consult with the Practice about my health. By signing this form below I agree to the following:
Name*

First NameLast Name
I understand that teleconsulting is not the same as a direct patient/provider visit due to the fact that I will not be present, in person, at the Practice.*

I AGREE
I understand that the Practice will provide information to assist in my understanding of certain medical conditions and will provide general counsel on health issues.*

I AGREE
I understand that there are potential risks by using this technology, including but not limited to the following: (1) the video connection may not work or that it may stop working during the consultation; (2) the video picture or information transmitted may not be clear enough to be useful for the consultation; and (3) there may be access by unauthorized persons due to the technology and breach of said technology by no fault of the Practice or me.*

I AGREE
I understand that the benefits of teleconsultation, including but not limited to, are the following: (1) I do not need to travel to the consult location and (2) I have access to a specialist through this method.*

I AGREE
I understand that the Practice or I can discontinue the teleconsult if it is felt that the connections are not adequate for the situation or if either of us feel that the consult has been comprised in any way.

I AGREE
I understand that my healthcare information may be shared with other individuals for scheduling purposes. I further understand that other individuals may also be present during the consultation in order to operate the video equipment. The above-mentioned people will take reasonable steps to maintain confidentiality of the information obtained. I also understand that I will be informed of their presence prior to the start of the consultation and will have the right to request the following: (1) omit specific details of my health history that are personally sensitive to me; (2) ask non-medical personnel to leave the teleconsult room: and or (3) terminate the consultation at any time.

I AGREE
I understand that it is solely my responsibility to contact my local healthcare provider and/or local hospital/emergency room for any healthcare emergency.*

I AGREE
I further agree that the Practice has the right to utilize any personal testimonials that I may write regarding my teleconsultations with the Practice, including those posted on any third-party websites. The testimonial may be conveyed or displayed in print, on the internet and in any other forms of media. Additionally, I waive any right to royalties or other compensation arising or relating to the use of my testimonial.*

I AGREE
While there have been no warranties, assurances, or guarantees made to me, I consent and freely agree to obtain teleconsultation from Ascent Physical Therapy, PLLC. I have read and understood the information provided in this Consent form, as well as all materials provided to me.*

I AGREE
I further agree to hold Ascent Physical Therapy, PLLC, the office and any associates or staff of the Practice harmless from any and all liabilities and claims, which may arise as a result of my participation in teleconsultation and the authorized use of such videotapes, digital recording films and photographs. I will not hold them responsible for the consequences of any decisions I may make, or any actions I may take, or may choose not to take, following the consultation.*

I AGREE
By initialing and signing below, I agree to communicate with the Practice through their HIPAA compliant e-mail. I agree to provide the Practice my choice of email and agree to update the Practice accordingly. I understand that if I choose to communicate in any other method, it is my responsibility to inform the Practice in writing. I understand that the Practice will respond to my emails within a reasonable period of time, but not to exceed 72 hours.*

I AGREE
I represent that I am of sound mind and am legally competent to understand and complete this agreement. I hereby execute this consent form without coercion.*

I AGREE
AGREEMENT STATEMENT - By clicking this box, I AGREE and certify that based on the above information I fully understand and consent to treatment with those at Ascent Physical Therapy and to the best of my knowledge understand the benefits and risks of doing so.*

I AGREE
Please verify that you are human*
Signature*

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Date*

MonthDayYear
Date
(MINORS ONLY) Checking this box below is a certification that the patient in question is a minor and I am responsible for their care. I hereby agree to informed consent to video/photograph this minor under my care.*

I AGREENot applicable
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