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Consent To Use Electronic Communications

CONSENT TO USE ELECTRONIC COMMUNICATIONS

basis for an informed discussion

This template is intended as a

. If used, physicians should adapt it to meet

the particular circumstances in which electronic communications are expected to be used with a patient.

Consideration of jurisdictional legislation and regulation is strongly encouraged .

PHYSICIAN INFORMATION:

Name:

Address:

Email (if applicable):

Phone (as required for Service(s)):

Website (if applicable):

The Physician has offered to communicate using the following means of electronic communication (“the Services”) [check all that apply]:

Videoconferencing (including Skype®, FaceTime®)

Text messaging (including instant messaging)

Website/Portal

Social media (specify):

Other (specify):

PATIENT ACKNOWLEDGMENT AND AGREEMENT:

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of th e selected

electronic communication Services more fully described in the Appendix to this consent form. I understand and accept the risks ou tlined

in the Appendix to this consent form, associated with the use of the Services in communications with the Physician and the P hysician’s

staff. I consent to the conditions and will follow the instructions outlined in the Appendix, as well as any other conditions that the

Physician may impose on communications with patients using the Services.

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.

Despite this, I agree to communicate with the Physician or the Physician’s staff using these Services with a full understanding of the risk.

I acknowledge that either I or the Physician may, at any time, withdraw the option of communicating electronically through th e Services

upon providing written notice. Any questions I had have been answered.

Patient name:

Patient address:

Patient home phone:

Patient mobile phone:

Patient email (if applicable):

Other account information required to communicate via the Services (if applicable):

Patient signature:

Date:

Witness signature:

Date:

Consent To Use Electronic Communications