Telehealth Consent Form

Please correct the errors described below.


The purpose of this form is to obtain your consent for a telehealth visit with the office of Jenny Welham MD LLC dba Island Pediatrics of Honolulu.

Telehealth is the delivery of healthcare services through the use of technology when the healthcare provider and patient are not in the same location. Health information is exchanged interactively from one site to another through electronic communications.

Electronically transmitted information may be used for diagnosis, therapy, follow up and/or patient education, and may include any of the following:

  1. Patient medical records
  2. Medical images
  3. Interactive audio, video, and/or data communications
  4. Output data from medical devices and sound and video files.

Potential Benefits
Improved access to medical care by enabling a patient to remain at home or a site remote from the physician office limiting exposure of patient and family to COVID-19

Potential Risks
Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s).The consulting physician(s) are not able to provide medical treatment to the patient through the use of telemedicine equipment nor provide for or arrange for any emergency care that the patient may requireDelays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.

  • I understand that I may opt-out of the telehealth visit at any time. This will not change my ability to receive future care at this office. I understand that the video visits are not recorded. I understand that Island Pediatric of Honolulu uses HIPAA compliant email (Paubox), texting (OhMD) , and video visit (OhMD, platforms.
  • I understand that due to the state of the current national emergency crisis, telehealth is offered to appropriate patients in an effort to comply with federal and state mandates of isolation and social distancing as an effort to provide protection to everyone. The purpose of telehealth visit is for medical care during the COVID-19 pandemic.
  • I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made by paging our office through Physicians' Exchange at (808) 524-2575 or by calling 911 to activate Emergency Medical Services.

By requesting or by accepting the invitation for electronic communication between and staff and Jenny Welham MD LLC dba Island Pediatrics of Honolulu, I certify that I have read and understand this agreement.

Patient Consent To The Use of Telehealth

I have read and understand the information provided above regarding telehealth, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my care.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.