E-visits Informed Consent Form

The purpose of this form is to obtain your consent to participate in a telemedicine consultation with the pediatrician, Dr. Angela Anderson.

Purpose and Benefits:

This project is intended to let patients do an e-visit to get medical care while in a location distant from the doctor and without the inconvenience of traveling to the doctor's clinic.

Nature of E-visit:

During the consultation, your child's medical history, scans, and/or x-rays, other medical tests shall be discussed with fellow physicians through real-time audio and video conferences. A physical exam, through remote means, may also take place. In addition, you may be able to see the non-medical staff. They are technicians and specialists in the information technology who may be present to ensure proper audio and video communication. For documentation purposes, the recording may take place during the session of the e-visit.

Risks and Consequences:

E-visits are visits similar to a visit to a medical clinic, except that one who visits does not go there physically. This method may feel uncomfortable or sometimes lacking satisfaction of the look and feel compared to actually visiting a clinic. 

Given the method's process, there are possibilities of inconveniences that may arise. In rare cases, intermittent connections to the internet may prevent proper communication between the parties. This may result to delay in diagnosis and consultation with the patient.

Medical Information and Records:

The management and administration of medical records of patients shall conform to the current laws of the state, and the same shall apply here in this agreement. For statistical purposes, there will be no need to ask for the patient or the patient's parent's consent for usage as this will not identify an individual. In any other case where the identity of the patient shall be known, consent will be sought from the patient or his/her parent or guardian.

Rights:

This informed consent is purely voluntary. In this regard, a patient may reject or withdraw from this informed consent at any time. This will not affect the right of the patient to future consultation or other healthcare services or treatment otherwise he is entitled to.

Payment:

It shall be the responsibility of the patient to secure whether his or her insurance, HMO, or other medicare service covers the fees and other payments for using the e-visit facility. Otherwise, the patient shall solely pay for the fees for the services provided by this e-visit.

I have read the information above or it has been read and explained to me, including the risks, consequences, benefits, or alternatives to the e-visit service as indicated above. I have had the opportunity to inquire about relevant questions and by which these were answered and explained to me to my satisfaction. I hereby declare that I give my consent to this e-visit with full knowledge and capacity and I was not coerced, harassed, or compelled in any way to sign this informed consent.