Telepsychiatry Consent Form

Telepsychiatry Consent Form
Purpose
The purpose of the Telepsychiatry Consent Form is to get the patient's permission and consent in order to participate in virtual psychological care and treatment services.

Telepsychiatry Consultation
Telepsychiatry is online psychological care for patients who do not want to visit the doctor's office physically. To receive the treatment, you can make an online appointment and select the appropriate date and time for you through the system.
Telepsychiarty sessions may not be the same as face-to-face sessions.

Confidentiality
I know that any law that protects my medical history records are also applied for telepsychiatry.

Patient Rights
I understand that I can revoke this consent at any time by contacting the Company and without risking my rights to future sessions.

Procedures, Benefits and Risks
During the procedure, video, audio or photo record of you can be taken.
During the Telepsychiatry sessions, your medical history, examinations and results can be discussed with other health professionals.
You don't have to wait for a long line to receive the psychiatric care on Telepsychiatry sessions.
I understand that I can take advantage of telepsychiatry, but that results cannot be guaranteed.
In case of any technical problem, a non-medical technician may be in the room during consultation.
Patient Name
First NameLast Name
Phone Number
Area CodePhone Number
Email
example@example.com
All the procedures, potential risks, consequences and benefits have been told to you by your health care professional. And you have given an opportunity to ask your concerns and questions which have been answered.
I sign this consent form on the behalf of
Name
First NameLast Name
What is your relationship with this person?
Phone Number
Area CodePhone Number
Email
example@example.com
Date of Sign
MonthDayYear
Date
Signature
Clear
Health Care Professional Name
First NameLast Name
Signature
Clear
Should be Empty: