Telehealth Consent Form

Welcome to Our Telehealth Services!

We are glad you chose our telehealth services for your healthcare needs. Please read this form carefully to understand how telehealth works and to give your consent.

What is Telehealth?

Telehealth allows you to meet with a healthcare professional using your computer, tablet, or phone. It’s like a video call where you can see and talk to your doctor without going to their office.

How Does It Work?
  • You will use a secure, private video platform.
  • You will need an internet connection and a device with a camera and microphone.
  • During the visit, the doctor can talk to you about your health, prescribe medication, and give medical advice.
Benefits of Telehealth
  • Convenience: No need to travel to the doctor’s office.
  • Safety: Avoid exposure to illnesses.
  • Comfort: See the doctor from your home.
Possible Risks
  • Technology issues: The video call might have technical problems.
  • Privacy concerns: Though we use secure systems, there is always a small risk of data breaches.
  • Limited examination: The doctor cannot physically examine you, which might limit the assessment.
Your Responsibilities
  • Be in a quiet, private place for your appointment.
  • Have a good internet connection.
  • Be honest and accurate about your health information.
  • Follow the doctor’s advice and ask questions if you do not understand.
Important Notices
  • This Service Cannot Replace Your Healthcare Professional Relationship.
  • Our service is a helpful digital medical tool for common health issues. It is not meant to replace your relationship with your healthcare professional(s).
  • If you are ever worried about your care or the treatment from this service, or if you think (or someone tells you) that you have a serious or life-threatening condition, call 9-1-1 (where available) or go to the nearest open clinic or emergency room.
  • THIS SERVICE IS NOT MEANT FOR SERIOUS, EMERGENCY, OR LIFE-THREATENING MEDICAL CONDITIONS AND SHOULD NOT BE USED IN THOSE SITUATIONS.
  • The medical advice from this service is based on your personal health information and the local standards of care for your symptoms based on your use of the service.
Privacy and Confidentiality
  • Your health information is private and protected by law.
  • We use secure systems to protect your data.
  • Your telehealth visit will not be recorded without your permission.
  • We send records of your visits to your primary care provider only if you ask us to or if the law says we have to.
Email, Cell Phone, or Text Usage for Healthcare Communications
If you provide an email address or cell phone number, you consent to receiving unsecure instructions and other healthcare communications via email or text at that address or number. These communications may include, but are not limited to:
  • Follow-up instructions
  • Educational information
  • Prescription information
  • Appointment reminders for medical care
Note: You can opt out of these communications at any time. Our practice/clinic does not charge for this service, but standard text messaging rates or cellular phone minutes may apply according to your wireless plan (contact your carrier for pricing details).
Payment
  • TM2Go is a cash-based service, so you must pay before getting treatment.
  • We don’t accept insurance but telehealth services may be covered by insurance. Check with your insurance provider.
  • If covered, you will need to apply for reimbursement yourself because TM2Go doesn’t bill insurance companies.
Your Rights
  • You can ask questions at any time.
  • You can stop using telehealth services whenever you want.
  • You can still visit the doctor in person if you prefer.
  • You can check your medical record on TravelMeds2Go whenever you want.
CONSENT

BY CHECKING THE BOX THAT YOU HAVE READ AND AGREE TO THE INFORMED CONSENT, YOU AGREE TO:

Thank you for trusting us with your healthcare needs!

Updated: 1/15/2025

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