Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

1. Nature of teleheatlh consult: during the telehealth consultation: *

a. Details of your medical history, examinations, x-rays, and tests will be discussed with other health care professionals through the use of interactive video, audio, and telecommunication technology. b. A digital physical examination may take place. c. A non-medical technician may be present in the telehealth studio to aid in the video transmission. d. Video, audio and/or photo recording may be taken of you during the procedure(s) or service (s) for treatment purposes only.

I agree and understand

2. Medical information and records: *

All existing laws regarding your success to medical information and copies of your medial records apply to this telehealth consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient identifiable images or information for this teleheatlh interaction to any other parties or entities shall not occur without your consent.

I agree and understand

3. Confidentiality: *

Reasonable and appropriate efforts have been made to eliminate any confidential risks associated with telehealth consultation and all existing confidentially protections under state and federal law apply to information disclosed during this telehealth consultation.

I agree and understand

4. Rights: *

You may withhold and withdraw your consent to the telehealth consultation at any time without affecting your right to future care or treatment.

I agree and understand

5. Risks, Consequences, and Benefits: *

You have been advised of all potential risks, consequences, and benefits of telehealth. Your health care provider has discussed with you the information provided above.

I agree and understand

Participation consent: *

I agree to participate in telehealth care with One Physical Therapy and Wellness for the procedure for the procedure(s) and/or service(s) above.

I agree