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Example: bachelor of science
Pt.$Name:$$$ $ Address
Telemedicine Consent Pt. Name: Address : City State Zip MRN: DOB: SEX: DOS: I. Introduction. Telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video or other electronic media. As such, telemedicine allows the provider to see and communication with the patient in real-time. II. Consent for Treatment. I voluntarily request UT Southwestern physician(s) and such associates, residents, technical assistants and other health care providers as they may deem necessary ( UT Southwestern Telemedicine Providers ) to participate in my medical care through the use of telemedicine.
tests or treatment(s). I authorize and consent to use of recordings, films, or other images of me (i.e., any photographic, vide o, electronic or audio media) for purposes of identification, diagnosis or treatment in connection with the care provided to me. 4. Agreements and Understandings: a.
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