Telemedicine Treatment Informed Consent

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RunYogaTherapy, PLLC

Telemedicine Treatment Informed Consent

I acknowledge, understand and state as follows:

  • I understand that telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver heath care services to patients when located at different sites.
  • I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
  • I UNDERSTAND THAT I MUST BE IN THE STATE OF VERMONT TO RECEIVE TELEMEDICINE PHYSICAL THERAPY SERVICES FROM RUNYOGATHERAPY, PLLC.
  • I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
  • If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that RunYogaTherapy PLLC or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
  • I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record.  I also understand that my refusal will not affect my right to future care or treatment.
  • I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
  • I understand that this document will become a part of my medical record.
  • I understand that I will not be physically in the same room as my health care provider.  
  • I have voluntarily chosen to seek telemedicine services with RunYogaTherapy PLLC.
  • I acknowledge and understand that the physical therapy is not an exact science, and that no promises or guarantees have been made concerning the outcome or results of my care and treatment from RunYogaTherapy PLLC.
  • As long as this consent is in force and effect (has not been revoked) RunYogaTherapy PLLC may provide healthcare services to me via telemedicine without the need for me to sign another consent form.
  • As part of my initial appointment, RunYogaTherapy PLLC staff will ask me a series of questions concerning my medical history for purposes of assessing the appropriate treatment and/or coaching to be furnished.  This information is critical to RunYogaTherapy PLLC’s services and I agree to answer each such question completely and correctly to the best of my knowledge.  Furthermore, I agree to inform RunYogaTherapy PLLC of any changes to my health during the course of my work with RunYogaTherapy PLLC.
(This acts as your legal and binding signature.)
(This acts as your legal and binding signature.)