Informed Consent for Telemedicine Services

I,_____, hereby provide my informed consent to engage in telemedicine services provided by BonCare. I understand and acknowledge the following:

1. Nature of Telemedicine Services: I understand that telemedicine involves the use of electronic communications to facilitate medical consultations and treatment remotely. This may include video conferencing, telephone consultations, secure messaging, and electronic transmission of medical records.
2. Limitations of Telemedicine: I acknowledge that telemedicine has its limitations and may not be suitable for all medical conditions or emergencies. While BonCare strives to deliver high-quality care through telemedicine, there may be instances where an in-person consultation or emergency services are necessary.
3. Privacy and Security: I understand that BonCare takes measures to protect the privacy and security of my personal and medical information during telemedicine consultations. However, I acknowledge that there are inherent risks associated with electronic communication, including the potential for unauthorized access or interception.
4. Medical Records: I consent to the collection, use, and storage of my medical records and personal information by BonCare for the purpose of providing telemedicine services. I understand that my medical records may be shared with healthcare providers involved in my care and may be subject to applicable privacy laws.
5. Treatment Decisions: I understand that the healthcare provider(s) at BonCare will make treatment recommendations based on the information provided during telemedicine consultations. I agree to follow these recommendations and understand that I have the right to refuse or seek a second opinion regarding any proposed treatment.
6. Emergency Situations: I acknowledge that in the event of a medical emergency or if I am experiencing a life-threatening condition, I should seek immediate medical attention by calling emergency services or visiting the nearest healthcare facility.
7. Costs and Fees: I understand that telemedicine consultations may be subject to fees, which may vary depending on my insurance coverage and the services provided. I agree to pay any applicable fees for telemedicine services rendered by BonCare.
8. Confidentiality: I understand that all communications with BonCare, including telemedicine consultations, are confidential and protected by applicable privacy laws. I agree to maintain the confidentiality of any information shared during telemedicine consultations.

By providing my informed consent, I acknowledge that I have read and understood the information provided above, and I voluntarily consent to participate in telemedicine services provided by BonCare.

Patient's Signature: _______________________

Date: _______________________

Patient's Name: _______________________

Patient's Date of Birth: _______________________

Patient's Address: _______________________