Please complete the Telemedicine consent form below:
- I understand that telemedicine is the use of electronic information and communication
technologies by a healthcare provider used to deliver services to an individual when he/she is
located at a different location or site than I am.
- I understand that the telemedicine visit will be done on, and is subject to the limitations of electronic platforms.
- I understand that the laws that protect privacy and the confidentiality of medical information also
apply to telemedicine.
- I understand that I will be charged a consultation fee for my telemedicine consultation. This
consultation includes a full history, assessment of clinical pictures sent to the doctor, a diagnosis
made and if needed a script sent to the pharmacy.
- I understand that I have the right to withhold or withdraw my consent to the use of telemedicine
during my care at any time, without effecting my right to future care or treatment.
- I understand that by agreeing to the above terms and conditions, I am consenting to receive health care services via