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Patient Verification & Telemedicine Based Consent

We are proceeding with this evaluation at your direct request. We ask that you verify with your provider your identifying information (to verify that you are the correct patient) and give verbal consent to perform this voluntary telemedicine encounter at the beginning of the visit. You (the patient/surrogate) understand that risks (including potential loss of confidentiality), benefits, alternatives, and the potential need for subsequent face to face care exist with telemedicine visits. You understand that there is a risk of medical inaccuracies given that our recommendations will be made based on reported data. Knowing that there is a risk that this information is not reported accurately, and that the telemedicine audio or data feed may be incomplete, you agree to proceed with evaluation and hold us harmless knowing these risks. In this evaluation, we will be providing recommendations only. You are being notified that other health care professionals (including students, residents and technical personnel) may be involved in this evaluation. All laws concerning confidentiality and patient access to medical records and copies of medical records apply to telemedicine.