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TeleMedicine Patient Consent

PURPOSE: The purpose of this form is to obtain your consent to participate in a telemedicine consultation.


During the telemedicine consultation:

a) Details of your medical history, examinations, xrays, and testing will be discussed through the use of interactive video, audio, and telecommunication technology.

b) A physical examination of you may take place.

c) A non-medical technician may be present to aid in video transmission.

d) Video, audio and/or photo recordings may be taken of you during any services rendered via video/audio.

Medical Information & Records

All existing laws regarding access to your medical information and copies of your medical records apply to this telemedicine consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent.


Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated the telemedicine consultation. All existing confidentiality protections under federal and Florida state law apply to information disclosed during this telemedicine consultation.


You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment.


You agree that any dispute arriving from the telemedicine consultation will be resolved in Florida, and that Florida law shall apply to all disputes.

Risks, Consequences & Benefits

You have been advised of all the potential risks, consequences and benefits of telemedicine. Your health care provider has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telemedicine consultation. All your questions have been answered, and you understand the information provided above.

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