TeleHealth Consent Form

Please fill out the applicable information!

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TeleHealth Consent Form

Please fill out the form below and we will get back to you as soon as we can.
 
Name *
E-mail *
Patient Address *
Date of Birth *
Please Select The Clinic You Would Like to Be Treated At: *
Please choose 1 Clinic
Purpose:
Purpose: The purpose of this form is to obtain your consent to participate in a Telehealth Consultation/Treatment in connection with the following procedure(s) and/or service(s)
1. Nature of Telehealth Consult: During the telehealth consultation:
a. Details of your medical history, examinations, x-rays, and tests will be discussed with other health care professionals through the use of interactive video, audio and telecommunication technology.
b. A digital physical examination may take place. c. A non-medical technician may be present in the telehealth studio to aid in the video transmission. d. Video, audio and/or photo recording may be taken of you during the procedure(s) or service(s).
c. A non-medical technician may be present in the telehealth studio to aid in the video transmission.
d. Video, audio and/or photo recording may be taken of you during the procedure(s) or service(s).
2. Medical Information & Records:
All existing laws regarding your success to medical information and copies of your medical records apply to this telehealth consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient identifiable images or information for this telehealth interaction to any other parties or entities shall not occur without your consent.
3. Confidentiality:
Reasonable and appropriate efforts have been made to eliminate any confidential risks associated with telehealth consultation, and all existing confidentiality protections under state and federal law apply to information disclosed during this telehealth consultation.
4. Rights:
You may withhold or withdraw your consent to the telehealth consultation at any time without affecting your right to future care or treatment.
5. Disputes:
6. Risks, Consequences & Benefits:
You have been advised of all the potential risks, consequences and benefits of telehealth. Your health care provider has discussed with you the information provided above.
I agree to participate in Peak Sports & Spine Physical Therapy Care for the procedure(s) and/or service(s) above.
Name *
By Entering Your Name, This Will Service As Your Digital Signature
Date *
If signed by someone other than the patient, indicate the relationship: *
 
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