Permission to Participate in Telehealth Consultation and Treatment

1. Purpose: The purpose of this Telehealth Permission Form is to get permission from patients to use the telehealth services during the treatment.

2. Medical Information & Records: Medical history and test details can be discussed with other professionals and can be used for further scientific studies. The patient will be contacted via video and audio during a telehealth appointment/visit. Video, audio, or any other digital photo of the patient can be recorded during the telehealth visit for treatment purposes only.

3. Patient Rights: The patient can withhold or withdraw the consent or permission to telehealth consultation/treatment at any time.

4. Risks and Consequences: The telehealth appointment/visit will be similar to the regular physical medical visit. Because this service uses videoconference technology, the visit may not be equivalent to or adequate as the regular physical visit. The patient may be recommended a visit physically after the telehealth visit by his or her physician.

5. Confidentiality: That is an obligation by the governmental laws to protect and kept private the personal or medical information of patients. All existing laws under federal will be for the physical treatment are also valid for telehealth treatment.

I have been informed about the potential risks, benefits of the telehealth practices and confidentiality of personal and medical information, and records. The opportunity to ask questions had been given to me and they were answered completely. I have understood the information and I have given my permission to participate in Telehealth Consultation.