Telemedicine Consent Form
To improve accessibility, Dr. Lin is excited to offer telemedicine visits via secure two-way video conferencing to his patients at Mango Medical Clinic. His patients would be able to use their webcam-enabled computers (Firefox or Chrome browsers), iPad/iPhone (iphone app), or Android smartphones (Chrome web browser) to have a video conference with him.

For more information, visit: http://mangomedical.ca/telemedicine/

Email address *
Patient Last Name *
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Patient First Name *
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Patient Date of Birth *
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Introduction
Telemedicine involves the use of electronic devices to enable 2-way communication between patients and their doctors at different locations for the purpose of diagnosis, therapy, follow-up and/or education. Transmitted information may include any of the following:
- Patient medical records
- Live two-way audio and video
- Patient materials such as prescriptions and lab requisitions may be sent to the patients via email upon request

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits
- Improved access to medical care by enabling a patient to remain in his/her home or workplace for simple issues such as medication refills or discussing lab results.
- More efficient medical evaluation and management.
Possible Risks
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
- In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
- Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
- In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
Patient Consent To The Use of Telemedicine
By signing this form, I understand the following:
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
- I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
- I understand that I have the right to inspect all information obtained in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
- I understand that I may choose to make an in-person appointment at any time.
- I understand that the doctor may recommend I schedule an in-person appointment to address issues that cannot be adequately addressed through telemedicine.
- I understand that telemedicine involves encrypted electronic communication of my personal medical information.
- I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
- Telehealth visit is an MSP-insured benefit. I understand that a fee of $85 per visit (subject to change) is applicable if I do not have current MSP coverage on the day of the tele-visit. I agree to pay all applicable fees upon receipt of invoice.
I agree that any dispute arriving from the telemedicine consult will be resolved in the Province of British Columbia.

I have read and understand the information provided above regarding telemedicine, have been offered the opportunity to discuss it with my physician, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

I hereby authorize DR. SHENG PING LIN of MANGO MEDICAL CLINIC (4392 Beresford St, Burnaby, BC V5H 0E7) to use telemedicine in the course of my diagnosis and treatment.

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Please have the patient or his/her legal representative type his/her full name as an electronic signature.
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A copy of your responses will be emailed to the address you provided.
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