Consent Form For Telemedicine
Please Print, Sign and Date This Form
The signed consent may be emailed to, faxed to our office at 231-798-9533, or uploaded as part of your telemedicine consultation.
Telemedicine involves using telecommunications technology to perform evaluation, diagnosis, consultation on, and treatment of a health condition.

Consent for Treatment: I voluntarily request Lakeshore Dermatology employees/associates (“Lakeshore Dermatology”) to participate in my medical care through the use of telemedicine.

I acknowledge that Lakeshore Dermatology ’ advice, recommendation, and/or decision may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure.

I understand that I will not be physically in the same room as my health care provider.

I understand that I have the right to stop participating in a telemedicine visit, and that my refusal will not affect my right to future care or treatment.

I understand that I will be responsible for any out-of- pocket costs such as copayments, coinsurances, or deductibles that apply to my telemedicine visit. I understand that health insurance plan payment policies for telemedicine visits may be different from policies for in-person visits.

If Lakeshore Dermatology determines that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented or an in-person medical evaluation may be necessary.

I understand that the disclosure of my medical information to Lakeshore Dermatology , including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that confidentiality may be compromised by failures or illegal and improper tampering with electronic data.

I agree that any dispute arriving from the telemedicine consult will be resolved in Michigan, and that Michigan law shall apply to all disputes.

I certify that this form has been fully explained to me, that I have read it or have had it read to me, and that I understand its contents.

____________________ _____________________________________________________________

Signature & date