By checking the box associated with “Informed Consent”, I acknowledge that I understand and agree with 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 written 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 telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas.

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.

5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. The above mentioned people will all maintain confidentiality of the information obtained.

Patient Consent to The Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, have discussed it with my physical therapist as may be designated, and all of my questions have been answered to my satisfaction.

I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.