Telehealth Consultation Consent

We want to make sure that you know:

A telehealth consultation will not be exactly the same as a face-to-face service and may not cover everything.
There could be some technical problems that affect a telehealth consultation.
Health professionals are allowed to take notes during a consultation.
We have taken measures to protect your privacy.

Your rights:

I can change my mind and stop using a telehealth consultation at any time, including in the middle of a telehealth visit.
If the telehealth consultation does not achieve everything that is needed, I will be given a choice about what to do next including a face-to-face visit or another telehealth consultation.

Recording video or images:

I agree there may be times when the video is recorded or a photograph is taken for health purposes. My health professional will advise before proceeding. This material will be sent and stored securely and only used to benefit my health care.

My consent relates to:

(Please tick all relevant boxes)

A single telehealth session; OR

An episode of care involving several telehealth sessions

The use of medical information for case conference

Recording video or images to benefit my health care

If over 16 years of age:

Given name (first name):

Surname (last name):

Preferred name:

Date of birth:

Contact number:

Client signature *

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Date:

If under 16 years of age/ in care/ with guardian:

Client's given name (first name):

Client's surname (last name):

Client's preferred name:

Client's date of birth:If you don't know the exact date, please provide client's age

Your given name (first name):

Your surname (last name):

Your relationship to the client:

Your contact number:

Your signature:

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Date: