Patient Consent Form — TeleHealth Connect

TeleHealth Connect

Secure & Confidential

Telehealth Consent Form

Please read carefully and sign below to confirm your consent for telehealth services

You have a consultation waiting

After signing this form you will be automatically redirected to your video session — Room:

Patient Information

First Name

Last Name

Email Address (optional — receive a visit summary after the call)

Consent for Telehealth Services

Telehealth involves the use of electronic communications — such as live video and audio technology — to deliver healthcare services when the patient and provider are in different locations.

By signing this form, I acknowledge and agree to the following:

I understand that my healthcare provider may use telehealth to diagnose, consult, treat, or educate me.
I understand that telehealth services may be provided via live video, audio, or other electronic means.
I acknowledge that telehealth offers convenient access but has limitations, and that certain conditions may require an in-person visit.
I understand that reasonable efforts will be made to protect the privacy and security of my health information.
I acknowledge that electronic communications carry potential risks, including technical failures or, in rare cases, unauthorized access.
I understand that I may refuse or discontinue telehealth services at any time without affecting my right to future care.
I voluntarily consent to receive healthcare services via telehealth.

Patient Acknowledgment & Signature

I have read and understand the information above. I had the opportunity to ask questions, and all my questions were answered to my satisfaction.

Your Signature

Draw your signature here

Date

Your information is transmitted securely and stored in accordance with applicable privacy regulations.

TeleHealth Connect · Developed by Ymath

Header

TELEHEALTH CONSENT FORM

Patient Information

First Name

Last Name

Consent for Telehealth Services

Telehealth involves the use of electronic communications (such as video and/or audio technology) to provide healthcare services when the patient and provider are in different locations.

By signing this form, I acknowledge and agree to the following:

I understand that my healthcare provider may use telehealth to diagnose, consult, treat, or educate me.
I understand that telehealth services may be provided via live video, audio, or other electronic means.
I understand that telehealth offers convenient access to healthcare but has limitations. I acknowledge that certain conditions may require an in-person visit.
I understand that reasonable efforts will be made to protect the privacy of my health information.
I acknowledge that electronic communication carries potential risks, including technical failures or unauthorized access.
I understand that I may refuse or discontinue telehealth services at any time without affecting my right to future care or treatment.
I voluntarily consent to receive healthcare services via telehealth.

Patient Acknowledgment

I have read and understand the information above. I had the opportunity to ask questions, and all my questions were answered to my satisfaction.

Signature

Date