Informed consent to the use of Telemedicine (videoconference)


Telemedicine involves the use of electronic communication to enable the physician at a different location than the patient to provide diagnosis, therapy, follow-up and/or education, and includes the following:

  • Live two-way audio and video.

The electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification.

Expected Benefits:

  • Improved access to medical care by enabling a patient to remain in his/her home (or at a remote site) while the physician is at distant/other site;
  • More efficient medical evaluation and management.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

  • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images, audio) to allow for appropriate medical decision making by the physician;
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.


By agreeing to this, I understand the following:


1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.

2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

3. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.

4. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

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