Telemedicine Agreement 

To participate in Telemedicine / Telehealth, patients will need to agree to the following:

Telemedicine / Telehealth Consent for Treatment: Spine & Sport Physical Therapy

I understand that I have the following rights with respect to telemedicine  / Telehealth and/or video consultation. By initiating and engaging in a scheduled telemedicine meeting I agree to the following:

a. Details of my medical history, examinations, x-rays, tests, may be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology. 

b. Video, and audio, and/or photo recordings may be taken during the consultation for the sole purpose of assisting me with retention of services / exercises conducted during the consultation. 

c. Please note, all telecommunications are not recorded or stored. Dissemination of any client identifiable images shall not occur without my consent.

Rights: I have the right to withhold or withdraw consent for telemedicine at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

Confidentiality: The laws that protect the confidentiality of my medical information also apply to telemedicine and/or video consultation. As such, I understand that the information disclosed by me during the course of my appointment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

I agree to participate in telemedicine / Telehealth as described above. 

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Stephens City, VA 22655

540-868-9599

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