Telemedicine Consent

Consent for Telemedicine Assessment and Treatment

I hereby authorize and direct FemGevity Health and the assistants, as necessary to perform quality care, to perform the following telemedicine consultation on me. I understand they will make recommendations for my diagnosis and treatments and it is up to my discretion on whether or not I complete those treatments.

I understand that the nature and purpose of the procedure/treatment, alternative methods of treatment, and potential risks and complications will be fully explained to me during my telemedicine visit and that I will have the ability to have all my questions answered, including but not limited to side effects, benefits, risk and alternatives.

I acknowledge that no guarantees have been made to me as to the outcome of the procedure(s) and/or treatment(s).

I grant this consent without duress, confusion, or pressure from my physician and/or staff, associates, or colleagues.

By signing this Authorization or by checking the related box, I am authorizing the use and disclosure of all information as outlined above.

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