Telehealth Consent Form - First Rivers Hospital

PURPOSE: The purpose of the "Telehealth Consent Form" is to gain the patient's consent in order to participate in telehealth appointments.

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.

TELEHEALTH INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telehealth 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 telehealth appointments and technical requirements for telecommunication.

Patient's Name

First

Last

Layout Phone Name

Date of Birth

Parent/Guardian Name

First

Last

Email

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Contact Number

Consent

Please check the box to agree.

I understand that all the laws that are protecting my privacy of medical history or information are also applied to telehealth 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 Telehealth for my treatment and diagnosis.

Signature

Clear Signature

Date