TELEMEDICINE INFORMED CONSENT
[Name of Provider] (the “Clinic”), which engages certain medical doctors and other providers of healthcare services (a “Provider”) and has arranged to provide certain services via telehealth which may include [describe services to be provided by telemedicine] (the “Services”). The Services may also include chart review, remote prescribing, appointment scheduling, refill reminders, health information sharing, and non-clinical services, such as patient education.
You, the undersigned, or your designee(s), on your behalf, agree to participate in the Services with the Provider. You agree that you have read, understand and consent to the following:
Eligibility Requirements and Acknowledgements
• You have secure access to personal on-line and/or mobile technology that will enable you to exchange information and communicate with the Provider in a confidential manner.
• You are NOT experiencing a medical emergency and are not in need of immediate medical attention. IF YOU THINK YOU HAVE A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.
Your Responsibilities
• You agree to follow all recommendations, protocols and other instructions provided by Clinic and/or the Provider. You understand that, if you decide or fail to follow any of these instructions, then you will be taking an action contrary to medical advice.