Telemedicine Consent Form

I understand that the health care provider Dr. Ankita Gandhir from Texas Kidney Specialists, P.A. (referred to as healthcare provider in this document) wishes to have a telemedicine consultation with the patient (referred to as "patient" in this document) . This means the patient and/or the healthcare provider or designee will, through interactive audio/video connection, be able to consult regarding patient's medical condition.

 

The healthcare provider has explained to the patient how the telemedicine technology will be used to do such a consultation. The patient  understands there are potential risks with this technology:

  1. The audio/video connection may not work or that it may stop working during the consultation.

  2. The audio/video picture or information transmitted may not be clear enough to be useful for the consultation.

  3. I may be required to go to the location of the consulting physician if it is felt that the information obtained via telemedicine was not sufficient to make a diagnosis.

 

The benefits of a telemedicine consultation are:

  1. Patient may not need to travel to the consult location.

  2. Patient has access to a specialist through this consultation.

The patient gives consent to a virtual visit with the healthcare provider. The patient also understands that other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained.

 

The patient understands that a limited physical examination will take place during the telemedicine visit and that the patient has the right to ask the healthcare provider to discontinue the telemedicine visit at any time. The patient understands that some parts of the exam may be conducted by individuals at the patient's location at the direction of the healthcare provider.

 

The patient authorizes the release of any relevant medical information about the patient to the consulting healthcare provider, any staff the healthcare provider supervises, third party payers and other healthcare providers who may need this information for continuing care purposes.

 

The patient hereby releases Dr. Ankita Gandhir and Texas Kidney Specialists, P.A. and its personnel and any other person participating in the patient's care from any and all liability which may arise from the taking and/or using recorded televisits for documentation purposes.

 

The patient has read this document and understands the risk and benefits of the telemedicine consultation and has had their questions regarding the procedure and televisit explained. The patient hereby provides consent to participate in a telemedicine visit under the conditions described in this document. The patient gives consent to a virtual telemedicine visit with the healthcare provider and the healthcare provider's staff. 

Thank You!