Consent for Telehealth:  

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Telehealth involves the delivery of healthcare services using electronic communications between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, one or more of the following:

  • Interactions between a patient and healthcare provider via audio, video and/or data communications

The medical care and treatment provided to you by your Provider(s) through the Service will be provided via telehealth.

The telehealth platform,, incorporates network and security protocols to protect the privacy and security of your information.

Anticipated Benefits

The use of telehealth by your Provider(s) through the Service may have the following possible benefits:

  • Making it easier and more efficient for you to access medical care and treatment

  • Allowing you to obtain medical care and treatment by Provider(s) at times that are convenient for you

  • Enabling you to interact with Provider(s) without the necessity of an in-office appointment

Possible Risks

While the use of telehealth can provide potential benefits for you, there are also potential risks associated with the use of telehealth. These risks include, but may not be limited to the following:

  • The information transmitted to your Provider(s) may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making  

  • The inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you

  • Your Provider(s) may not able to provide medical treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services

  • Delays in medical evaluation/treatment could occur due to unavailability of your Provider(s) or deficiencies or failures of the technology or electronic equipment used

  • The electronic systems or other security protocols or safeguards used in the Service could fail, causing a breach of privacy of your medical or other information

  • Given regulatory requirements in certain jurisdictions, your Provider(s) diagnosis and/or treatment options, especially pertaining to certain prescriptions, may be limited (for example, narcotics cannot be prescribed via telehealth)

  • A lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors



By agreeing to the Consent Box on I agree: 

  •  That I have read or had this form read and/or had this form explained to me

  •  That I fully understand its contents including the risks and benefits of the procedure(s).

  •  That I have been given ample opportunity to ask questions and that any questions have  been answered to my satisfaction.

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Forrestal Professional Center

10 Forrestal Road South

Suite 205

Princeton, NJ 08540
Tel: 609-924-2230
Fax: 609-924-5006

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