Telehealth Visit Consent

Effective Date: Date✕

Organization: Organization Name✕

Participant / Signer: Full Name✕

I consent to receive healthcare services from Provider Name✕ via secure video and audio technology. I understand that telehealth has technological limitations and is not appropriate for emergencies.

Assumption of Risk

I acknowledge that the activities described above involve known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to me, to property, or to third parties. I understand that such risks cannot be eliminated without jeopardizing the essential qualities of the activity. I voluntarily and knowingly assume all such risks.

Release and Waiver of Liability

In consideration of being permitted to participate, I, on behalf of myself and my heirs, assigns, personal representatives, and next of kin, hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Organization Name✕, its officers, directors, employees, agents, contractors, and volunteers (the "Released Parties") from any and all liability, claims, demands, actions, and causes of action arising out of or related to any loss, damage, or injury that may be sustained by me or to any property belonging to me, whether caused by the negligence of the Released Parties or otherwise, while participating in such activity.

Indemnification

I agree to INDEMNIFY AND HOLD HARMLESS the Released Parties from any loss, liability, damage, or costs they may incur due to my participation, whether caused by my negligence or otherwise.

Medical Treatment

I authorize Organization Name✕ to obtain or provide emergency medical treatment as may be necessary, and I agree to be responsible for all costs associated with such care and transportation.

Governing Law and Severability

This agreement shall be governed by the laws of the State of State✕. If any provision is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.

Acknowledgment

I have read this entire document, understand it fully, and agree to be legally bound by its terms. I sign it freely and voluntarily, without any inducement.