Telehealth Acknowledgment & Consent Form

Purpose of Telehealth

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share medical information for the purpose of improving patient care.
Telehealth may include consultation, treatment, diagnosis, education, and care management using secure video, audio, messaging, and electronic health record systems.

Nature of Telehealth Services

During your telehealth visit, you may be asked to:

Discuss your medical history, medications, and symptoms

Provide recent lab results, weight, or photographs (if applicable)

Communicate via secure video call, phone, or HIPAA-compliant messaging

You understand that your provider will assess your health and determine whether a prescription, medication, or other treatment plan is appropriate for you.

Benefits of Telehealth

Convenient access to licensed providers without travel

Reduced wait times for appointments and follow-ups

Access to medical expertise from the comfort of your home

Possible Risks of Telehealth

You acknowledge that there are potential risks associated with telehealth, including:

Limited ability for physical examination

Potential delays due to technology or connection issues

In rare cases, incomplete data may affect medical decision-making

Security breaches are unlikely but possible in any online system

Confidentiality

All medical information shared via telehealth is protected under HIPAA and other applicable privacy laws.
Your data will be securely stored in MediDuce Wellness’s electronic health record system and used only for your medical care.
No video or audio sessions will be recorded without your consent.

Patient Rights

You have the right to:

Withdraw your consent at any time

Request an in-person consultation (where applicable)

Ask questions about the telehealth process or your treatment plan

Access your medical records upon request

Patient Acknowledgment

By ticking the box, you acknowledge that:

You have read and understand the information above.

You understand that telehealth is voluntary and can be stopped at any time.

You understand the potential risks and benefits of telehealth services.

You consent to receive medical care, evaluation, follow-up, and/or treatment via telehealth through MediDuce Wellness.