Student Health & Wellness Office
P.O. Box 496006, 11555 Old Oregon Trail, Redding, CA 96049-6006
Phone: (530)242-7580 / Fax: (530) 225-4968
I Drive > Wellness > Telehealth > TH Consents & Checklists > FILLABLE 2020 Telehealth Informed Consent
o If you are unreachable at this point, please call or email to reschedule non-urgent appointm
o If your provider assesses any urgent safety issues, they will immediately follow up with initiation of emergency
If you are experiencing an emergency, including a mental health crisis, please call 911, or the Suicide Prevention Hotline 1-800-273-
8255, or text “courage” to 741741 or go to your nearest emergency room.
So that your provider is able to get you help in the case of an emergency, the following are important and necessary. By signing this
agreement form you are acknowledging that you understand and agree to the following:
• You must inform your provider of your location at the beginning of each appointment.
• You must identify a person who can be contacted in the event that your provider believes your safety is at risk.
PATIENT RESPONSIBILITIES: By participating voluntarily in TeleHealth, you agree to comply with the following terms:
• You will only engage in appointments when you are physically located in California. Your provider will ask you to confirm
this at the start of each appointment.
• You will provide a valid government issued photo ID (driver's license, state issued ID, etc.) at the beginning of each
appointment. This is required to protect your identity / confidentiality. If unable to do so, your appointment will be re-
• You are responsible for the privacy and security of the location where you choose to engage in Telehealth appointments.
You are responsible for ensuring private and confidential information regarding your health is not overheard or interrupted
by unauthorized persons.
• You are responsible for the security of any computer or device you use to engage in a Telehealth appointment. You are
advised against using any publicly accessible computer or device to engage in a Telehealth appointment. You understand if
you use a public or employer computer you may compromise your privacy.
• You are responsible for the security of any internet connection you use to engage in a Telehealth appointment. You are
advised to use only private internet connections or public connections in conjunction with a Virtual Private Network service.
• You are responsible for the functionality and security of any computer or device you use, including installation of
appropriate operating systems and anti-virus software.
• You will not make any audio, video, or other digital recording of any appointment.
• Shasta College Student Health & Wellness Office will not make any audio, video, or other digital record of your
appointments without your written consent.
Emergency Contact (Name, Relationship and Number):
Person of Support (Name, Relationship and Number) if different from above:
• I acknowledge and understand the attendant risks involved with TH and voluntarily and willingly assume those risks as a
condition of participating.
• I have read and understand the information provided above. I have discussed it with my provider and all of my questions have
been answered to my satisfaction.
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