TeleHealth

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I understand that TeleHealth is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to Liberty Healthcare Inc. providing health care services to me via TeleHealth. 

I understand that the laws that protect privacy and the confidentiality of medical information also apply to Telehealth. As always, your medical records may be access by quality review/audit. 

I understand that I will be responsible for any fees that apply to my Telehealth visit. 

I understand that I have the right to withhold or withdraw my consent to the use of Telehealth in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting Liberty Healthcare at clinic@libertyhealthcare.ca or 289-315-3663. As long as this consent is in force (has not been revoked) Liberty Healthcare may provide health care services to me via Telehealth without the need for me to sign another consent form.

Possible Risks

These risks include, but may not be limited to:

· In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider and consultant(s);

· Delays in medical evaluation and treatment could occur due to the deficiencies or failures of the equipment;

· In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information. 

· In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors