E-Visit Informed Consent Form

Explain to patients how virtual medical visits work and obtain their consent before starting care.

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Purpose of E-Visits

What to Expect During an E-Visit

Technology Requirements

Privacy and Confidentiality

Risks and Limitations

Voluntary Participation

Right to Withdraw Consent

Patient Acknowledgment

Age of Consent

I confirm that I am of legal age to give consent

Patient Name

First Name

Last Name

Email

Date

Signature

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Guardian/Representative Name

First Name

Last Name

Relationship to Patient

Guardian's Email

Date

Guardian's Signature

Sign here

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