Scroll Top

Telehealth Consent

Telehealth Consent Form


By signing this form, I understand and agree with the following:

Viking Alternative Medicine, LLC whose physical address is 132 Chesterfield Center, Chesterfield, MO 63005, utilizes telehealth to provide high quality care to all of it’s patients. Telehealth, also known as telemedicine, involves the use of electronic communications to enable health care providers in various locations to share patient information for diagnosis purposes, therapy recommendations, follow up consultations, and/or education. The medical practitioners involved in my care may include but are not limited to a supervising physician, physician’s assistants, nurse practitioners, registered nurses, medical assistants, and other HIPAA certified professionals. The qualifications, certifications, and identification of our medical practitioners can be found on our staff page.

Telemedicine requires transmission of health information through the internet via electronic devices ranging from computers to handheld devices and may include:

  • Progress reports, assessments, or other intervention-related documents
  • Bio-physiological data transmitted electronically
  • Videos, pictures, text messages, audio, and any digital form of data

The laws that are currently in place for protected health information will be applied to the data obtained during a telehealth visit. Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except for the purposes of treatment, education, billing, and healthcare operations. By agreeing to use the telehealth/telemedicine services, I am consenting to Viking Alternative Medicine LLC. making a recording of my consultation for Viking's use, sharing my information with certain third parties as more fully described in Viking Alternative Medicine, LLC. Privacy Policy. I understand, agree, and expressly consent to Viking Alternative Medicine, LLC. obtaining, using, storing, and disseminating to necessary third parties, information about me, including my image, as necessary to provide these services.

As with any Internet-based communication, I understand that there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of my identity and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

Telehealth sessions may not always be possible due to disruptions of signals or problems with the Internet’s infrastructure. Issues related to this may cause problems such as poor picture or sound quality, dropped connections, audio interference that prevent effective interaction between consulting clinician(s), patient, or care team.

I hereby release Viking Alternative Medicine, LLC, and all members of my care team from any responsibility pertaining to any loss of data due to technical failures associated with the telehealth/telemedicine service.

I understand and agree that the health information I provide at the time of my service will be the only source of health information used by the medical professionals during my evaluation and treatment at the time of my telehealth/telemedicine visit.

I understand that I will be given information about test(s), treatments(s) and procedures(s), as recommended, including the benefits, risks, possible problems or complications, and alternate choices for my care during the telemedicine visit.

All my questions have been answered to my satisfaction.

I hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and conditions.

By signing below, I certify that I am the legal representative of the participant or that I am the patient and am 21 years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the above statements. I have had all my questions answered. I understand that this informed consent will become a part of my medical record.

Patient Name
MM slash DD slash YYYY

Rev date 10/30/2023