Submit a ticket

Informed Consent for Telehealth Visit

To provide more accessible healthcare services, we now offer medical consultations through video, audio, or electronic information transmission, collectively referred to as "telehealth." Telehealth allows healthcare providers to evaluate, diagnose, manage, and treat various health issues from a remote location. It is crucial that you understand and provide informed consent for the use of telehealth in your care.

DISCLAIMER: Telehealth is not suitable for medical or mental/behavioral health emergencies. In case of a medical emergency, dial 911. For a mental/behavioral health emergency, you can: (1) call 911; (2) go to the nearest emergency room; or (3) contact your local crisis center.

Telehealth: Telehealth involves using electronic communications to enable healthcare providers, including physicians, psychiatrists, nurse practitioners, physician assistants, licensed professional counselors, and social workers, to evaluate, diagnose, manage, and treat various health issues, including mental/behavioral health. Information may include patient medical records, medical images, live video and/or audio, and data from medical devices.

Information Collection:
We collect a child's name from children under 13 to provide services. No contact will be made using their email address or username.

We may collect information about a child's use of our services, such as domain names, browser types, and device information through cookies and similar technologies.

How We Use Information:
To provide healthcare services.
To respond to customer service and support requests.
We de-identify and/or aggregate information for research and analysis.

Possible Risks:
Transmitted information may be of inadequate quality, requiring a face-to-face meeting.
Delays in evaluation and treatment due to equipment issues.
Security protocol failures may lead to privacy breaches.Lack of access to complete medical records may result in errors.

By agreeing to this HIPAA Authorization Form, you acknowledge:
Privacy laws apply to telehealth.
Your information won't be disclosed without consent, except in emergencies, abuse cases, court orders, billing claims, evaluations, and where legally required.
You can withdraw consent at any time.
You understand telehealth alternatives.Information may be shared with out-of-state practitioners.
Benefits are not guaranteed.

Call 911 for immediate medication side effects.
Health information may be shared for scheduling and billing, with confidentiality maintained.

Electronic Signature: I have read and understood this HIPAA Authorization Form, including associated risks and benefits of telemedicine (including, but not limited to, the risks and benefits associated with teleconferencing by video, audio, or other electronic means). My questions have been answered, and I provide informed consent for telemedicine visits.

My ability to access Viclinic Service is conditional upon this informed consent, which Viclinic Healthcare Providers rely on to facilitate healthcare services.
I understand and acknowledge that my ability to access the Viclinic Service is conditional upon the above-mentioned criteria of my informed consent, and that Viclinic ’s Healthcare Providers are relying upon this informed consent in order to interact with and facilitate health care services to me.

Contact Us: If you have questions or need assistance, contact at

Ready for the future of telehealth?

Become a part of healthcare’s next generation.
Join ViClinic now!

for Physicians
ViClinic Web login
Download on the App StoreGet on Google Play