Telemedicine Consent Form: Dr. Dorothy Reddy

Dr. Dorothy Reddy (referred to as “the physician”) has offered to communicate using the following means of electronic communication or services: telephone, Email, text messaging, Videoconferencing, and via website/portal.

Please review the consent form below and sign  at the bottom of the page if you agree.

Consent to use Communication Devices:

1) I acknowledge that I have read and fully understand the risks, limitations, and conditions of use, and instructions for use. 

2) I have fully read and understand the selected electronic communication Services, more fully described in the Appendix A, B, C to this consent form.

3) I understand and accept the risks, outlined in Appendix A, B, C associated with the use of the Services in communications with the Physician and the Physician’s staff. 

4) I acknowledge that the Physician may change the type of device being used for communication with patients. An example, switching from video to telephone for appointments or vice versa.

5) I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the Physician or the Physician’s staff, using the Services may not be encrypted. 

6) I acknowledge that the Physician or I may, at any time, withdraw the option of communicating electronically (telephone, e-mail, video or other) by providing written notice. I understand that the means of communication will terminate immediately upon receipt of the written notice.

7) I understand that The Physician will use reasonable means to protect the security and confidentiality of information sent and received using the Services. However, because of the risks outlined below, the Physician cannot guarantee the security and confidentiality of electronic communications.

8) Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information.

9) I understand that the use of electronic communications to discuss sensitive information can increase the risk of such information being inadvertently disclosed to third parties.

10) I understand that electronic communications can introduce malware into a computer system, potentially damaging disrupting the computer, networks, and security settings.

11) I understand that there is a risk that electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Physician or the patient.

12) I understand that even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.

13) I acknowledge that electronic communications may be disclosed in accordance with a duty to report or a court order.

14) I understand that videoconferencing may be more open to interception than other forms of communication.

Appendix A: Communication via e-mail and text

If the email or text is used as an e-communication tool, I acknowledge that the following are additional risks:

1) Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.

1) Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient is able to read the message once it has been sent.

Appendix B: Conditions of using the Services

1) While the Physician/ Physician’s staff will attempt to review and respond in a timely fashion to my electronic communication,  they  cannot guarantee that all electronic communications will be reviewed and responded to within any specific period of time. The Services will not be used for medical emergencies or other time-sensitive matters.

2) For urgent issues, I acknowledge that I will attend the nearest Emergency Department as necessary. If I require immediate assistance, or if my condition appears serious or rapidly worsens, I should not rely on the Services. Rather, I should take measures as appropriate, such as going to the nearest Emergency Department or urgent care clinic.

3) If my electronic communication requires or invites a response from the clinic  and I have not received a response within a reasonable time period, I acknowledge that it is my responsibility to follow up to determine whether the intended recipient received the electronic communication and when the recipient will respond.

4) I understand that I am  responsible for following up on the clinic’s electronic communication and for scheduling appointments when warranted.

5) I acknowledge that electronic or telephone communication is not an appropriate substitute for in-person communication or clinical examinations. 

6) I understand that electronic communications concerning diagnosis or treatment may be printed or transcribed in full and made part of my medical record. Other individuals authorized to access the medical record, such as staff and billing personnel, may have access to those communications.

7) I understand that the Physician may forward electronic communications to staff and those involved in the delivery and administration of my care. The Physician might use one or more of the Services to communicate with those involved in my care. The Physician will not forward electronic communications to third parties, including family members, without my prior written consent, except as authorized or required by law.

8) I acknowledge that neither the Physician nor I, will  use the Services to communicate sensitive medical information about matters specified below: Sexually transmitted disease, AIDS/HIV, Mental health, Developmental disability, and/or Substance abuse.

9) I agree to inform the Physician of any types of information that I do not want sent via the Services, in addition to those set out above. I  can add to or modify the above list at any time by notifying the Physician in writing.

10) I understand that some Services might not be used for therapeutic purposes or to communicate clinical information. Where applicable, the use of these Services will be limited to education, information, and administrative purposes.

11) I understand that the Physician is not responsible for loss of my information due to technical failures associated with my software or internet service provider.

Appendix C: Instructions for communication using the Services

To communicate using the Services, I understand that I must:

1) Reasonably limit or avoid using an employer’s or other third party’s computer.

2) Inform the Physician of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate via the Services.

3) If  the Services include email, instant messaging and/or text messaging, I understand that I must Include in the message’s subject line an appropriate description of the nature of the communication (e.g. “prescription renewal”), and my full name in the body of the message.

4) Review all electronic communications to ensure they are clear and that all relevant information is provided before sending to the physician.

5) Ensure the Physician is aware when I receive an electronic communication from the Physician, such as by a reply message or allowing “read receipts” to be sent.

6) Take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.

7) Withdraw consent only by written communication to the Physician.

8) I understand that just like online shopping or email, Virtual Care has some inherent privacy and security risks that my health information may be intercepted or unintentionally disclosed. 

We want to make sure you understand this before we proceed. 

1) I acknowledge In order to improve privacy and confidentiality, I should also take steps to participate in this virtual care encounter in a private setting and should not use an employer’s or someone else’s computer/device as they may be able to access my information. Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.

2) I acknowledge that I am responsible for ensuring that I have complete privacy before contact. 

I am aware of the risks of Virtual Care and I consent to telehealth which includes email, telephone and virtual communication. Any questions I had, have been answered and clarified.

Physician: Dr. Dorothy Reddy