top of page


Telemedicine is a general term that covers all of the ways you and your doctor can use technology to communicate without being in the same room. Telemedicine includes phone calls, video chats, emails, and text messages. Telemedicine can also be referred to as telehealth, digital medicine, e-health, or m-health (for “mobile”).

Telemedicine Patient Consent Form

I agree to receive this health care service.

A Telemedicine visit means that my provider at Southern Oregon Wellness has determined that a telemedicine visit is appropriate and will happen using special audiovisual equipment. 

As a Telemedicine Patient, I understand that:

  • I can decline the Telemedicine service at any time without affecting my right to future care or treatment.

  • I may have to travel to see a health care practitioner in-person if I decline the Telemedicine service.

  • If I decline the Telemedicine service, the other options/alternatives available for me, including in-person services, are available in our office. 

  • The same HIPAA protections that apply to my other medical care also apply to the Telemedicine service.

  • I will have access to all medical information resulting from the Telemedicine service as provided by law. 

  • The information from the Telemedicine service (images that can be identified as mine or other medical information from the Telemedicine service) cannot be released to anyone else without my additional written consent. 

  • I agree to an "in-person" visit if the doctor decides it's necessary. 

  • Therefore, by agreeing to this consent, I am giving permission to release information to my insurance company or third party payer.  


bottom of page