DATE OF BIRTH:
PHYSICIAN NAME: Yves Eveillard,MD
Informed Consent for Telemedicine Services
Telemedicine involves the use of electronic communications for the purpose of diagnosis, therapy, follow-up and/or education, and may
include any of the following:
Patient medical records
Live two-way audio and video
Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and
imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Improved access to medical care by enabling a patient to remain at home or at remote site
More efficient medical evaluation and management.
Obtaining expertise of a distant specialist.
As with any medical procedure, there are potential risks associated with the use of telemedicine.
These risks include, but may not be limited to:
In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical
decision making by the physician and consultant(s);
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information; • In rare cases, a
lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
By signing this form, I understand the following:
I. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no
information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time,
without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may
receive copies of this information for a reasonable fee.
4. i understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any
My psychiatrist has explained the alternatives to my satisfaction.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners
who may be located in other areas, including out of state.
6. I understand that it is my duty to inform my psychiatrist of electronic interactions regarding my care that I may have with other healthcare
7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or
Patient Consent To The Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as
may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of
telemedicine in my medical care.
I hereby authorize Yves Eveillard,MD to use telemedicine in the course of my diagnosis and treatment.
Signature of Patient (or person authorized to sign for patient)
If authorized signer, relationship to patient:
I have been offered a copy of this consent form (patient’s initials) _