Telemedicine Patient Consent Form

Name: Pediatrics of Sugar Land
Address: 16651 Southwest Fwy #180, Sugar Land, Texas, 77479, US
Telephone: +12812658800

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

Patient Name

First

Last

Date of Birth

Mobile Number

Email address*

Reason for the Telemedicine Visit

Nature of Telemedicine Consult: During the telemedicine consultation:
- Details of your medical history, examinations, x-rays, and test will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology.
- A physical examination of you may take place.
- A non-medical technician may be present in the telemedicine studio to aid in the video transmission.
- Video, audio, and/or photo recordings may be taken of you during the procedure(s) or service(s)
Medical information and records: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation.
Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation, and all existing confidentiality protections under federal and Texas state law apply to information disclosed during this telemedicine consultation.

Rights: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
Risks, consequences & benefits: You have been advised of all the potential risks, consequences, and benefits of telemedicine. 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 written information provided above.

I agree to participate in a telemedicine consultation

Yes

Name, Signature of Patient / Guardian*

This field should be left blank