Patient forms

Telemedicine Consent.

Telemedicine lets us care for you wherever you are. Please review how it works and what to expect.

About telemedicine

Telemedicine is the use of secure video, phone, and messaging technology to deliver healthcare when you and your provider are not in the same room. It allows AmpleHealth to evaluate, diagnose, and treat many conditions remotely.

Benefits. Telemedicine can improve access to care, reduce travel time, and let you connect with your provider from the comfort of home.

Limitations. In some cases your provider may determine that an in-person visit is necessary. Telemedicine is not appropriate for medical emergencies — if you are experiencing an emergency, call 911.

Privacy & security. We use technology designed to protect your privacy. As with any electronic communication, there is a small risk that information could be intercepted; we take reasonable steps to minimize this risk.

Your rights. Your consent to telemedicine is voluntary. You may withhold or withdraw your consent at any time without affecting your right to future care or treatment.

Location requirement. AmpleHealth providers are licensed in California. To receive care, you must be physically located in California at the time of your visit.

Acknowledgment
Signature

By submitting, you confirm the information above is accurate to the best of your knowledge.