Consent Form

TELEMEDICINE CONSENT FORM

Your First Name (required)

Your Last Name (required)

Date of Birth (required)

Insurance ID# (required)

1. PURPOSE:
The purpose of this form is to obtain your consent to participate in a telemedicine consultation in connection with the following Podiatry procedure(s) and/or service(s)

2. NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation.
a. Details of your medical history, examinations, x-rays and test will be discussed through the use of interactive video, audio and telecommunication technology.
b. A physician examination of you make take place.
c. Video, audio and/or photo recordings may be taken of you during the procedure(s) or service(s)

3. MEDICAL INFORMATION & RECORDS:
All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Please note, note all telecommunications are recorded and stored. Additionally, dissemination of any patient identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consult.

4. CONFIDENTIALITY:
Reasonable and appropriate efforts have been made to eliminate and confidentiality risks associated with the telemedicine consultation and all existing confidentiality protections under federal and Louisiana state law apply to information disclosed during this telemedicine consultation.

5. RIGHTS:
You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment.

6. RISK, CONSEQUENCES & BENEFITS:
You have been advised of all the potential risks, consequences ans benefits of telemedicine. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telemedicine consultation. All your questions have been answered and you understand the written information provided above.

I agree to participate in telemedicine consultations for the procedure(s) described above.
SIGNATURE: Please sign in the purple box below.(required)

If signed by someone other than the patient, indicate relationship. (required)

You have been advised of all the potential risks, consequences and benefits of telemedicine.
YESNO