Consent to Participate in a Telemedicine Appointment

Terms of Service:

  1. I understand that my health care provider wishes me to engage in a telemedicine consultation using

  2. My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

  3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my healthcare provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

  4. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation.

  5. I have had a direct conversation with my healthcare 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.

By agreeing to 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.