STEP 1:  CONSENT FOR TELEHEALTH

Please read and agree by digitally signing below

  1. I understand that my health care provider wishes me to engage in telehealth.

  2. My health care provider explained to me how the video conferencing technology that will be used to affect such an interaction and will not be the same as a direct client/health care provider session due to the fact that I will not be in the same room as my provider.

  3. I understand that a telehealth 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 consult/session 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 in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH SERVICE via Doxy.me 

Doxy.me is the technology service we will use to conduct telehealth videoconferencing appointments. 

 By signing this document, I acknowledge:

  1. Telehealth via Doxy.me is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

  2. I do not assume that my provider has access to any or all of the technical information in the Telehealth via Doxy.me – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth via Doxy.me .

  3. To maintain confidentiality, I will not share my telehealth appointment information with anyone unauthorized to attend the appointment.

By signing this form, I certify:

  • That I have read or had this form read and/or had this form explained to me

  • That I fully understand its contents including the risks and benefits of the procedure(s).

  • That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

  I AGREE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.  I AM ALSO AGREEING TO THESE TERMS AND CONDITIONS FOR MY ENTIRE FAMILY THAT IS ESTABLISHED WITH THE PRACTICE.

Digital Signature:

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