Telehealth Consent Form

By signing this form, I voluntarily consent to receive healthcare services via telehealth (audio/video communication technology) from Modern Primary Care Plus.

I understand that:

• Telehealth involves electronic communication of my personal medical information.
• The laws that protect the confidentiality of medical information also apply to telehealth.
• I have the right to withhold or withdraw consent at any time without affecting my right to future care.
• There are potential risks including technology failures, interruptions, or limitations in the ability to perform a physical exam.
• My healthcare provider may determine that telehealth is not appropriate for my condition and may recommend an in-person visit.

I am responsible for providing accurate and complete health information. Benefits may include:

Benefits may include:

• Improved access to healthcare from any location.
• Reduced travel time and waiting room exposure.
• Convenience and flexibility of scheduling.