Consent to Participate in a Telemedicine Appointment (2020)

1. I understand that my health care provider wishes me to engage in a telemedicine consultation using Doxy.me and/or iPhone Facetime
2. My health care provider has explained to me how the Doxy.me and/or iPhone Facetime video conferencing technology will be 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 Doxy.me and/or iPhone Facetime 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:
   • Omit specific details of my medical history/physical examination that are personally sensitive to me;
   • Ask non‐medical personnel to leave the telemedicine examination room: and or
   • 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 Doxy.me and/or iPhone Facetime telemedicine consultation.
6. 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 signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me
• That I fully understand its contents including the risks and benefits of the procedure(s)

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.

I am the patient, parent, or guardian of the following patients: