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Informed Consent to Telemedicine/Telephone/Telepharmacy Consultation

You are scheduled for a telemedicine/telephone/telepharmacy consultation.  Prior to your visit, is important that you read and understand this document. 

By signing this document, you are attesting that you understand:
1.	The purpose is to assess and treat your medical condition.
2.	This consult is done through a two-way communication whereby the physician or other health provider at TTUHSC can see your image on the screen and/or hear my voice. However, unlike a traditional medical consult, the physician or other health provider does not have the use of the other senses such as touch or smell; and it may not be equal to a face-to-face visit.
3.	Since we are in different locations, we must rely on information provided by you. TTUHSC and affiliated telemedicine/telephone/telepharmacy consultants rely on your accurate and complete information to provide appropriate care.
4.	You can ask questions and seek clarification of the procedures and telemedicine technology.
5.	You can ask that the telemedicine exam and/or videoconference be stopped at any time.
6.	You know there are potential risks with the use of this new technology. These include but are not limited to:
•	Interruption of the audio/video link.
•	Disconnection of the audio/video link
•	A picture that is not clear enough to meet the needs of the consultation
•	Electronic tampering.
If any of these risks occur, the procedure might need to be stopped.
7.	The consultation may be viewed, heard or videotaped by medical and non-medical persons for evaluation, informational, research, educational, quality, technical purposes, or as might be required by my health coverage plan. 
8.	You understand you can make a complaint of your provider to the Texas Medical Board.

If you have any questions or concerns about this document, please make sure to ask your nurse or healthcare provider.

Printed Name: ______________________________________

Signature: __________________________________________

Date: ______________________________________________

Revised March 17, 2020