1. I understand that Woodinville Pediatrics has recommended to me that I engage in a telehealth appointment. These visits are by scheduled appointment only. If I connect without an appointment, I may be disconnected without warning.

2. Woodinville Pediatrics has explained to me how the telehealth technology will be used to connect me with a provider. Telehealth appointments may be conducted by videoconferencing, video images, still (high quality photo) images, or by telephone conference. I have had the alternatives to a telehealth appointment explained to me, and in choosing to participate in a telehealth appointment, I understand that this appointment will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. 

3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telehealth appointment if it is felt that the videoconferencing connections are not adequate for the situation. I understand that I can discontinue the telehealth appointment at any time.

4. The telehealth appointment may not be recorded by either party.

5. I understand that billing for the telehealth consultation will occur from Woodinville Pediatrics Clinic, PLLC. 

6. I have read this document carefully, and understand the risks and benefits of the telehealth appointment and have had my questions regarding the procedure explained. By participating in a telehealth appointment visit I am hereby consenting to the terms described herein.