Telemedicine Consent

Telemedicine Consent to Treat

1. I understand that my health care provider wishes me to engage in a telemedicine visit.
2. I understand how the video conferencing technology used to accomplish such a visit 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. My questions have been answered and any practical alternatives have been discussed with me in a language in which I understand. I further understand that I will be informed of who is present during the telemedicine visit and have the right to terminate the telemedicine visit at any time.
3. 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 telemedicine visit if it is felt that the videoconferencing connections are not adequate enough for the situation.
4. I have had the alternatives to a telemedicine visit explained to me, including scheduling a face to face in office visit with my health care provider. By acknowledging this form, I certify: I have read or had this form read and/or explained to me That I fully understand its contents, including the risks and benefits of telemedicine visits That I have been given ample opportunity to ask questions and that the questions have been answered to my satisfaction.
5. I understand that the audio or video portion of this visit will not be recorded by ExpressCare Urgent Care Centers other than written documentation in my medical record. I also understand that I may not record this session by any means without permission of ExpressCare Urgent Care management.