Telemedicine consent form

• I understand that telemedicine is the use of electronic information and communication
  technologies by a healthcare provider used to deliver services to an individual when he/she is
  located at a different location or site than I am.
• I understand that the telemedicine visit will be done on, and is subject to the limitations of electronic platforms.
• I understand that the laws that protect privacy and the confidentiality of medical information also
  apply to telemedicine.
• I understand that I will be charged a consultation fee for my telemedicine consultation. This
  consultation includes a full history, assessment of clinical pictures sent to the doctor, a diagnosis
  made and if needed a script sent to the pharmacy.

• I understand that all appointments must be cancelled at least 24 hours in advance, by failing to do this I may be charged for a late penalty cancellation fee.

• I understand that I have the right to withhold or withdraw my consent to the use of telemedicine
  during my care at any time, without effecting my right to future care or treatment.
• I understand that by agreeing to the above terms and conditions, I am consenting to receive health care services via
  telemedicine.