Saratoga Spine
31 Myrtle Street
Saratoga Springs, NY 12866
Telephone: (518) 587-7746 Fax: (518) 743-1018
1
Consent for Telehealth Services
Remember to find a private place where you can talk as it will be a video conference and can be
seen and overheard by people around you. You can use your computer, tablet or smart phone. No
information will be stored with any third-party platform other than the electronic medical record
system already used by our practice.
Please answer the following questions:
1. Are you able to access a smartphone, tablet or computer? □Yes □No
If no, do you have a friend or family who could help you in and leave so you have privacy? □Yes □No
2. Do you have a room that is well lit for the online sessions so the Doctor can clearly see you? □Yes □No
If no, where are you planning to talk with the Doctor?
3. Do you have any questions or concerns about this change in how your care and treatment will be
delivered? □Yes □No If yes please explain it here:
4. Do I have your consent for Telemedicine/Videoconferencing sessions? □Yes □No
If no, ask why:
5. How would you like to get the link for your Telemedicine/Videoconferencing sessions
□ E-mail
____________________________________________________________________________________
□ Text message link: Mobile number_______________________________
Mobile Carrier (ATT, Verizon etc.) ___________________________________
You will get a link before the appointment which will take you directly to the virtual waiting room and we will
connect with you once we see you there and completes the previous patient appointment.
I agree- please sign and date below print out your name and DOB
_____________________________________________________ Date _______________________________
Name:________________________________________________ DOB:________________________________
