Office of Audra Dahl
TELEHEALTH CONSULTATION CONSENT
I understand that my provider wishes me to engage in a telehealth
My provider explained to me how the video conferencing technology
that will be used to affect such a consultation will not be the
same as a direct client/health care provider visit due to the fact
that I will not be in the same room as my provider.
I understand that a telehealth consultation has potential benefits
including easier access to care and the convenience of meeting from
I understand there are potential risks to this technology,
including interruptions, unauthorized access, and technical
difficulties. I understand that my healthcare provider or I can
discontinue the telehealth consult/visit if it is felt that the
videoconferencing connections are not adequate for the situation.
I have had a direct conversation with my provider, during which I
had the opportunity to ask questions in regard to this procedure.
My questions have been answered and the risks, benefits and any
practical alternatives have been discussed with me in a language in
which I understand.
CONSENT TO USE THE PIXIDOC SERVICE
PixiDoc is the technology service we will use to conduct telehealth
video-conferencing appointments. It is simple to use and there are no
passwords required to log in. By signing this document, I acknowledge:
PixiDoc is NOT an Emergency Service and in the event of an
emergency, I will use a phone to call 911.
Though my provider and I may be in direct, virtual contact through
the Telehealth Service, neither PixiDoc nor the Telehealth Service
provides any medical or healthcare services or advice including,
but not limited to, emergency or urgent medical services.
PixiDoc facilitates video-conferencing and is not responsible for
the delivery of any healthcare, medical advice or care.
I do not assume that my provider has access to any or all of the
technical information in the PixiDoc Service – or that such
information is current, accurate or up-to-date. I will not rely on
my health care provider to have any of this information in the
To maintain confidentiality, I will not share my telehealth
appointment link with anyone unauthorized to attend the
By signing this form, I certify:
That I have read or had this form read and/or had this form
explained to me
That I fully understand its contents including the risks and
benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that
any questions have been answered to my satisfaction.
BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ,
UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.