1. I understand that my health care provider wishes me to engage in a telemedicine consultation.
2. I verify that I am in the state of Oregon during the telemedicine consultation.
3. My health care provider has explained to me how the video conferencing technology will be used and that a telemedicine consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.
6. I have had the alternatives to a telemedicine consultation explained to me, and I am choosing to participate in a telemedicine consultation.
7. I understand that billing will occur from my practitioner.
8. I have been given the opportunity to ask questions about this telemedicine consultation. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

By agreeing below, I certify:

• That I have read or had this form read and/or had this form explained to me.
• That I fully understand its contents including the risks and benefits of the procedure(s).
• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.