Free Chiropractic Clinic Telehealth Consent Form

Please read carefully and sign below.

Consent Agreement

By signing this form, I acknowledge and agree to the following:

1. Purpose of Telehealth Services: I understand that telehealth is used for diagnosis, consultation, treatment, education, and care management remotely.

2. Privacy and Security: I understand that reasonable efforts are made to protect the privacy and security of telehealth communications. However, there is a potential risk of unauthorized access to electronic information.

3. Limitations of Telehealth: I understand that telehealth services may not be as complete as in-person care. If deemed necessary, I may need to schedule an in-person visit.

4. Billing and Insurance: I understand that telehealth services are billed similarly to in-person visits and may be covered by insurance depending on my plan.

5. Right to Refuse or Withdraw: I understand that I have the right to refuse or withdraw consent for telehealth services at any time without affecting my right to future care or treatment.

Acknowledgment and Consent

I have read and understood the information provided above regarding telehealth services. I give my informed consent to participate in telehealth services with my chiropractor.

Name:

Date:

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