Patient Consent Form — TeleHealth Connect

1

Patient Information

Your basic details for this consultation

First Name *

Last Name *

Email Address optional — receive a visit summary after the call

2

Consent for Telehealth Services

Please read all items carefully before signing

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, I acknowledge and agree to all of the following:

I have read and understand all of the above. I had the opportunity to ask questions, and all my questions were answered to my satisfaction. I voluntarily agree to receive telehealth services.

3

Digital Signature

Sign below with your finger or mouse to complete

Draw your signature

Sign here

Date *

Telehealth Consent Form

Consent Submitted!