Consent for Telehealth Services

I hereby authorize Complete Foot and Ankle Specialists to use the telehealth practice platform for Telemedicine/Videoconferencing sessions for evaluating and diagnosing my medical condition.
I understand no information will be stored with any third-party platform other than the electronic medical record system already used by our practice.
I understand that technical difficulties may occur before or during the telehealth sessions which may affect my appointment, causing it to not start or end as intended.
I agree my physician can contact me via an interactive video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
I understand telehealth visit charges are billed and collected in the same manner as for regular in-office visits.

Please answer the following questions:

1. Are you able to access a smartphone, tablet, or computer?

Yes No

2. Do you have a room that is well lit for the online sessions so the Doctor can clearly see you?

Yes No

3. How would you like to get the link for your Telemedicine/Videoconferencing sessions?

E-mail

Text message link

Email address:

Mobile Number:

Mobile Carrier (Must be entered):

You will get a link before the appointment which will take you directly to the virtual waiting room and your physician will connect with you once we see you there.

I, [Enter Name Below] have read and understand the information provided above regarding my telemedicine appointment. I hereby give my informed consent for the use of Telemedicine/Videoconferencing sessions for my care.

Patient Name:

Patient Date of Birth:

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

Signature:

Today’s Date:

Your information will be encrypted.