Tele Medicine Consent Form

I authorize NP Health Clinic to utilize telemedicine technologies in determining my diagnosis and/or treatment. I understand telemedicine means the practice of healthcare delivery, diagnosis, consultation, treatment and transfer of medical data through interactive audio, video or data communications that occurs in lieu of the physical presence of the patient or MD/NP.

NP Health Clinic
www.nphealthclinic.ca
289-404-4763

Will be consulted through audio, video or data imaging and communications

Benefits
The reason telemedicine is being utilized is for the following reason(s):
➢ Convenience of encounter for the patient.
➢ Access to healthcare technology not physically readily available.
➢ Need for expertise from a consultant not readily available.

Risks
The reasonably foreseeable risks of utilizing telemedicine technologies may include:
➢ Audio or visual images may not be as good as in person.
➢ Telemedicine Nurse Practitioner cannot utilize the senses of touch and
smell to assist in diagnosis, treatment or therapy.
➢ Telemedicine Nurse Practitioner cannot obtain their own set of vital signs.

Alternatives
The possible alternatives may be:
➢ Travel distance to physically see my NP/Health care provider or
undergo testing/procedure.
➢ Undergo therapy available locally which may not produce desired
result.
➢ Go to local urgent care or emergency room.

Confidentiality
I understand every reasonable effort will be made to protect the security and confidentiality of my medical information which is
copied and forwarded to the above named office, either through the mail or transmitted through electronic means as part of
telemedicine.

Do not sign unless you have read and thoroughly understand this form.