Chiropractic Clinic Telehealth Consent Form
Please read carefully and sign below.
Consent Agreement
By signing this form, I acknowledge and agree to the following:
Purpose of Telehealth Services: I understand that telehealth is used for diagnosis, consultation, treatment, education, and care management remotely.
Privacy and Security: I understand that reasonable efforts are made to protect the privacy and security of telehealth communications. However, there is a potential risk of unauthorized access to electronic information.
Limitations of Telehealth: I understand that telehealth services may not be as complete as in-person care. If deemed necessary, I may need to schedule an in-person visit.
Billing and Insurance: I understand that telehealth services are billed similarly to in-person visits and may be covered by insurance depending on my plan.
Right to Refuse or Withdraw: I understand that I have the right to refuse or withdraw consent for telehealth services at any time without affecting my right to future care or treatment.
Acknowledgment and Consent
I have read and understood the information provided above regarding telehealth services. I give my informed consent to participate in telehealth services with my chiropractor.
Name:
Date:
Form Templates @ Template.net
![]()
Thank you for your submission!
We appreciate you taking the time to submit.
Create free forms at
