STEP 1: CONSENT FOR TELEHEALTH
Please read and agree by digitally signing below
I understand that my health care provider wishes me
to engage in telehealth.
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
I understand that a telehealth has potential
benefits including easier access to care and the
convenience of meeting from a location of my
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.
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:
Telehealth via Doxy.me is NOT an Emergency
Service and in the event of an emergency, I will use
a phone to call 911.
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 .
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
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