Telemedicine/Telehealth: Consent to Participate in a Telemedicine Appointment

The inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery

The quality of transmitted data may affect the quality of services provided by the provider

Changes in the environment and test conditions could be impossible to make during delivery of telehealth services; Telehealth services may not be provided by correspondence only.

  • The use of telehealth for this service is voluntary
  • You may stop the telehealth visit at any time and request a face-to-face service
  • You will have access to information resulting from the telehealth service provided by law
  • Doxy.me our telehealth platform uses HIPAA compliant 128 bit encryption
  • You have the right to exclude anyone from your telehealth visit
  • You have the right to object to videotaping or other recording of consult
  • Telemedicine does not take the place of a consultation w/ your primary care provider
  • You must be 18 years or older

I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties.

I understand that video conferencing technology will be used for the consultation and will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

I understand that the responsibility of the telemedicine consulting specialist is to give medical advice and that the specialist’s responsibility will conclude upon the termination of the Doxy.me video conference connection.

I had the opportunity to ask questions in regard to this procedure including risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

By joining the video conference link, I certify:

  • That I have read or had this form read and/or had this form explained to me
  • That I fully understand its contents including the risks and benefits of the procedure(s).
  • That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction

Acknowledgement of Notice of Privacy Practices

I have been presented with a copy of the Notice of Privacy Practices for St. Louis South Oral Surgery by going the HIPAA Privacy Policy page. This page details how my information may be used and disclosed as permitted under federal and state law.

I hereby and voluntarily consent to authorize St. Louis South Oral Surgery healthcare providers at their service locations and telehealth platforms to provide health care services to me. The health care services may include, without limitation the following: diagnostic tests, procedures, examinations, routine laboratory procedures and tests including blood, urine, and other studies as well as procedures and treatment prescribed St. Louis South Oral Surgery’s medical staff. I understand that this consent is valid and remains in effect as long as I am a patient of St. Louis South Oral Surgery. The consent will remain in full force until revoked in writing. I understand that although every effort will be made to keep all risks and side effects to a minimum; risks, side effects, and complications can be unpredictable both in nature and severity; I understand that “Physician Extenders” including Physician Assistants and/or Advance Practice Nurses will be involved in my treatment. I understand that St. Louis South Oral Surgery evaluates many conditions and the assessment of my condition can be limited to the diagnostic test available. I will contact my primary health care provider for any other specific medical questions I have regarding my medical condition(s) and/or treatment(s).  I hereby voluntarily give my consent to treatment at St. Louis South Oral Surgery and its telehealth services by joining the video conference link.