Virtual Visit Consent

When you schedule a virtual visit, you agree to the following terms:

Consent to participate in a telemedicine appointment 

1. I have requested to engage in a telemedicine consultation using 

2. I am aware that the video conferencing technology 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 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 nonā€medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time. 

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

6. 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. 

7. Children under the age of 18 will be accompanied by a responsible adult, unless the visit is for mental health.