Telehealth consent

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

telehealth consultation.

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

situation.

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

conference connection.

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

procedure.

* That I have been given opportunity to ask questions and that any questions

have been answered to my satisfaction.