* Required Information
Patient Information

  I, the undersigned patient, hereby consent to engage in telehealth services with Syntax Medical Services.

Nature of Telehealth Services

 I understand that telehealth involves the use of electronic communications to enable healthcare providers to deliver services to patients remotely. This may include but is not limited to, videoconferencing, audio communication, and other forms of electronic communication.

Benefits and Risks

 I acknowledge that the benefits and risks of telehealth services are similar to those of in-person healthcare services. Telehealth services may provide a convenient and efficient way to receive healthcare, but there may be limitations in the ability to conduct a physical examination.

Privacy and Security

 I understand that Syntax Medical Services. will take reasonable steps to ensure the privacy and security of the telehealth session, but there are inherent risks associated with electronic communication. I consent to the use of telehealth services, acknowledging the potential for unauthorized access by third parties despite reasonable security measures.

Emergency Situations

 I understand that telehealth services may not be appropriate for all types of medical conditions or emergencies. In case of a medical emergency, I will seek immediate in-person care and call 911 or go to the nearest emergency room.

Alternate Care Options

 I acknowledge that I have the right to choose an in-person consultation with a healthcare provider and that telehealth is an alternative means of receiving healthcare services.

Records and Confidentiality

 I understand that my telehealth session may be recorded for quality and record-keeping purposes and that the same confidentiality and privacy regulations apply as in in-person healthcare services.

Insurance Coverage

 I understand that telehealth services may or may not be covered by my insurance, and I am responsible for checking with my insurance provider regarding coverage.

Consent Duration

 This consent will remain valid unless revoked by either party. I have the right to revoke this consent at any time by providing written notice to Syntax Medical Services.

 I have read and understand the information provided above, and I hereby give my informed consent to participate in telehealth services with Syntax Medical Services.

By submitting this form you agree to the terms of the Privacy Policy.

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