Consent for telemedicine

I understand the following:

The purpose of the app is to assess and treat my medical condition.

The telemedicine consultation  is done through a two-way video link-up whereby the physician or other health provider at a hospital can see my image on the screen and hear my voice. However, unlike a traditional medical consultation, the physician or other health provider does not have the use of the other senses such as touch or smell; and it may not be equal to a face-to-face visit.

Since the telemedicine consultants practice in a different location and do not have the opportunity to meet with me face-to-face, they must rely on information provided by me or my onsite healthcare providers. GRAPES IDMR and affiliated telemedicine health care providers can not be responsible for advice, recommendations and/or decisions based on incomplete or inaccurate information provided by me or others. 

The telemedicine consultation will be similar to a routine medical office visit, except interactive video technology will allow you to communicate with a health care provider at a distance. The use of video technology to deliver healthcare services is a new technology and may not be equivalent to direct patient to health care provider contact. Following the telemedicine consultation, your health care provider may recommend a visit to a hospital for further evaluation.

I know there are potential risks with the use of this new technology. These include but are not limited to:  

  • Interruption of the audio/video link. 
  • Disconnection of the audio/video link
  • A picture that is not clear enough to meet the needs of the consultation
  • Electronic tampering. 

If any of these risks occur, the procedure might need to be stopped. 

The consultation may be viewed by medical and non-medical persons for evaluation, informational, quality, or technical purposes. 

I understand the examination may be videotaped for internal quality review  however the video images will only be used for those purposes unless further authorized below. 

I will not receive any royalties or other compensation for taking part in this telemedicine consultation or associated with any use by the health care provider

I understand and agree to its contents. I volunteer to participate in the telemedicine examination. I authorise Grapes IDMR/associate health care providers/Doctors/nurses and other providers involved to perform procedures that may be necessary for my current medical condition.

I certify that I have read this fully and agree to it.