Scott Boyd
Scott Boyd

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TELEHEALTH CONSULTATION CONSENT

  1. I understand that my provider wishes me to engage in a telehealth consultation.

  2. 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.

  3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from anywhere.

  4. 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.

  5. 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:

  1. PixiDoc is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

  2. 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.

  3. PixiDoc facilitates video-conferencing and is not responsible for the delivery of any healthcare, medical advice or care.

  4. 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 PixiDoc Service.

  5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

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.