Patient Consent for Telehealth Services


I understand that Telehealth is a mode of delivering health care services via communication technologies (e.g. Internet or phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.

By acknowledging my consent below, I understand and agree to the following:

  1. I understand that Community Wellness Physicians provides Telehealth consultations, which are conducted through store and forward or videoconferencing technology and my healthcare provider will not be present in the room with me.
  2. I understand there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties. I understand that either my healthcare provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit.
  3. I understand that I could seek an in-office physician visit rather than obtain care from Community Wellness Physicians, and I am choosing to participate in a Telehealth consultation.
  4. I understand that my healthcare information may be shared with others for scheduling or billing purposes.
  5. In an emergent situation, I understand that the responsibility of my Telehealth provider may be to direct me to emergency medical services, such as an emergency room.
  6. I understand that my unauthorized recording (audio, video, still photography, etc.) of my Telehealth visit with a Community Wellness Physicians provider is strictly prohibited.

By acknowledging below, I certify:

  • that I have read this form and/or had it explained to me
  • that I understand the risks and benefits of a Telehealth appointment
  • that I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction.

Revised: 2020-06-12