1. I understand that my health care provider wishes me to engage in a
2. My health care provider has explained to me how the video
conferencing technology will be used. 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 telehealth consult/visit if it is
felt that the videoconferencing connections are not adequate for the
4. I understand that if others are present during the consultation other than my
health care provider, they will maintain confidentiality of the information
obtained. I further understand that I will be informed of their presence in the
consultation and thus will have the right to request the following: (1) omit
specific details of my medical history/physical examination that are personally
sensitive to me; (2) ask non‐clinical personnel to leave the telehealth
examination room: and or (3) terminate the consultation at any time.
5. I have had the alternatives to a telehealth consultation explained to me, and
in choosing to participate in a telehealth consultation.
6. In an emergency, I understand that the responsibility of the telehealth
consulting specialist is to advise my local practitioner and that the specialist’s
responsibility will conclude upon the termination of the video
7. 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 giving verbal consent this form, I certify:
* That I have read or had this form explained to me
* That I understand its contents including the risks and benefits of the
* That I have been given opportunity to ask questions and that any questions
have been answered to my satisfaction.