Informed Consent for Telemedicine Services Informed Consent for Telemedicine Services Patient Name Date of Birth The purpose of this form is to obtain your consent to participate in a telemedicine appointment with Concordia Mind Health. During the appointment, I understand that details of my medical records will be discussed. I understand that there are risks with using technology, such as interruptions, unauthorized access, and technical difficulties. I understand that the appointment may be ended if the connection is not adequate for the situation. I have had the opportunity to discuss any questions or concerns regarding the telemedicine appointment with the clinic and my questions have been answered to my satisfaction. Our clinic will ensure confidentiality during these appointments. I agree to participate in the telemedicine appointment with Concordia Mind Health. Signature signature keyboard Clear If signed by someone other than patient, please indicate relationship: reCAPTCHA If you are human, leave this field blank. Submit
