Consent for Telehealth

1. I understand that my health care provider wishes me to engage in a telehealth and in person visit consultation.
2. My health care provider explained to me how the video conferencing technology that will be used to conduct such a consultation will not be the same as a direct client/health care provider visit since I will not be in the same room as my provider.
3. I understand that a telehealth consultation has potential benefits, including easier access to care and the convenience of meeting from a location of my choosing.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consultation/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered, and the risks, benefits, and any practical alternatives have been discussed with me in a language that I understand.

By signing this form, I certify that I have read or had this form read and/or explained to me, and that I fully understand its contents, including the risks and benefits of the procedure(s). I have been given ample opportunity to ask questions, and any questions have been answered to my satisfaction.

By signing below, I am agreeing that I have read, understood, and agree to the items contained in this document.