Telemedicine Consent

What is Telemedicine?

Telemedicine allows treatment providers to evaluate, diagnose, and treat patients at a distance using telecommunications technology without an in-person visit. Treatment is provided via a real-time, two-way, secure video and audio connection between the treatment provider and patient. Telemedicine is frequently used for follow-up visits, management of chronic conditions, medication discussions & refills, and a host of other clinical services.

Telemedicine: Your Rights

Telemedicine allows treatment providers to evaluate, diagnose, and treat patients at a distance using telecommunications technology without an in-person visit. Treatment is provided via a real-time, two-way, secure video and audio connection between the treatment provider and patient. Telemedicine is frequently used for follow-up visits, management of chronic conditions, medication discussions & refills, and a host of other clinical services.

Telemedicine: Your Rights

  1.  Humane treatment that is courteous, considerate, and respects my personal dignity at all times.

  2. Protection of my civil rights and liberties, including no unlawful discrimination in the provision of services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion

  3. Enrollment in treatment programs with an adequate number of competent, qualified, experienced staff.

  4. Receive a plan for treatment appropriate to my needs, in accordance with clinical and regulatory guidelines.

  5. Give informed consent for treatment based on a reasonable understanding of treatment options and their expected benefits/substantial risks, including informed written consent regarding participation in a research study.

  6. Make decisions regarding my care, including remaining informed of the content in the plan for treatment.

  7. Obtain mental health services designed to offer a reasonable opportunity for improving my condition, in accordance with standards of professional practice.

Telemedicine: Your Responsibilities

  1.  Humane treatment that is courteous, considerate, and respects my personal dignity at all times.

  2. Protection of my civil rights and liberties, including no unlawful discrimination in the provision of services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion

  3. Enrollment in treatment programs with an adequate number of competent, qualified, experienced staff.

  4. Receive a plan for treatment appropriate to my needs, in accordance with clinical and regulatory guidelines.

  5. Give informed consent for treatment based on a reasonable understanding of treatment options and their expected benefits/substantial risks, including informed written consent regarding participation in a research study.

  6. Make decisions regarding my care, including remaining informed of the content in the plan for treatment.

  7. Obtain mental health services designed to offer a reasonable opportunity for improving my condition, in accordance with standards of professional practice.

Telemedicine: Potential Benefits, Constraints, Risks

  1.  Humane treatment that is courteous, considerate, and respects my personal dignity at all times.

  2. Protection of my civil rights and liberties, including no unlawful discrimination in the provision of services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion

  3. Enrollment in treatment programs with an adequate number of competent, qualified, experienced staff.

  4. Receive a plan for treatment appropriate to my needs, in accordance with clinical and regulatory guidelines.

  5. Give informed consent for treatment based on a reasonable understanding of treatment options and their expected benefits/substantial risks, including informed written consent regarding participation in a research study.

  6. Make decisions regarding my care, including remaining informed of the content in the plan for treatment.

  7. Obtain mental health services designed to offer a reasonable opportunity for improving my condition, in accordance with standards of professional practice.

In signing below, I acknowledge that I read and understand the information above



    Please let parent, guardian, or your personal representative sign below:


    By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.