Telemedicine Consent Form

Home Telemedicine Consent Form

Consent For Telemedicine Treatment

Dr Mehak Nagpal


1. I understand that I will be participating in an out-patient telemedicine evaluation/examination and diagnosis and treatment and am choosing to do so.

2. I understand how the video conferencing technology will be used for the evaluation/examination and that I will not be in the same room as my health care provider.

3. I have understood the benefits and any practical alternatives to video consultations

Expected Benefits:

Better access to healthcare with decrease in wait time
Less travel time
More non-business hours appointments.
Obtaining expertise of a distant specialist
More Privacy

I also understand there can be interruptions, delays and technical difficulties during the consultation and I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

4. I understand that my healthcare information will be kept confidential and used only for the purpose of my treatment

5. In an emergency situation, I understand that if advised by my healthcare provider I must access locally available medical facilities.

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 regarding the telemedicine consultation.

Date of Birth

Date of Consent

I Agree