CONSENT FOR TELEHEALTH CONSULTATION
If you have any questions about telehealth, please email [email protected] or call [+1 (833) 748-0728](tel:+1 (833) 748-0728). Your questions will be answered and the risks, benefits and any practical alternatives will be discussed with you in a language in which I understand.
- I understand that my healthcare provider wishes me to engage in a telehealth consultation.
- I understand that video conferencing technology will be used for my consultation and that a telehealth consultation is not the same as a direct client/healthcare provider visit due to the fact that I will not be in the same room as my provider.
- I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
- I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
- I have the opportunity to ask Wellory questions in regard to this procedure.
- I understand that I will be present at the telehealth appointment. It is my responsibility to be in a safe and reasonably private space during my telehealth visit. The practice will not provide services to me if I operating a motor vehicle, or am otherwise distracted. If my provider determines that a session cannot take place for these reasons, it will be considered a Late Cancellation, and a Late Cancellation fee will be charged.
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 including the risks and benefits of the procedure(s).
- That I have been given ample opportunity to ask questions and any questions have been answered to my satisfaction.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.