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Telehealth Consent

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Consent to Telehealth Services

Purpose:
This form explains how telehealth will be used to provide your care and asks for your consent. By signing below, you agree to receive healthcare services through Calm Tides Psychiatry’s online platform (“Service”).

What Telehealth Is

Telehealth uses secure technology to allow you to meet with your healthcare provider (physician, nurse practitioner, or physician assistant) through video, audio, messaging, or the transfer of medical records and images. Telehealth may be used for diagnosis, treatment, follow-up, and patient education.

You may choose in-person care at any time if available.

Benefits

  • Easier and more convenient access to care

  • Ability to see specialists without travel

  • Reduced time away from work or family

  • Continuity of care through electronic communication

Risks & Limitations

Telehealth has some risks:

  • Technology may fail (audio/video problems, software issues, delays).

  • Providers may not be able to do a complete physical exam.

  • Certain tests or treatments may require in-person care.

  • Telehealth may not be appropriate for all conditions.

Emergencies

Telehealth is not for emergencies.

  • If you are in crisis, call 911 or go to the nearest emergency room.

  • For urgent technical problems, call (843)-299-2033.

Privacy

We use secure systems to protect your information. Your records and communications are protected by HIPAA. Information will not be shared without your consent unless required by law.

Your Rights

  • You may withdraw consent at any time by written notice.

  • Withdrawal will not affect past care but may limit future telehealth services.

  • You have the right to use any pharmacy of your choice.

Your Responsibilities

  • Provide accurate and complete health information.

  • Follow treatment recommendations or discuss alternatives with your provider.

  • Understand that your provider will decide if telehealth is appropriate for your care.

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Acknowledgment & Consent

By acknowledging this consent, you confirm that:

  • You understand the benefits and risks of telehealth.

  • You understand that telehealth is not the same as in-person care.

  • You consent to receive healthcare services through telehealth.

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