*Please agree to the below consent form to schedule your ACM Health Line consultation

Informed Consent for TeleHealth Consultations with ACM Health Line

"TeleHealth" means that you may be evaluated and treated by a health care provider or specialist from a distant location via electronic communication. Since this may be different than the type of consultation with which you are familiar, it is important you understand and agree to the following statements:

  • The consulting health care provider will be at a different location from me. Additional medical or registration personnel may also be present in the room with the Provider.
  • I understand that my voice and image may be recorded. I consent to this audio and video recording.
  • I understand there are potential risks to this technology, including, but not limited to, interruptions, unauthorized access and technical difficulties. I understand there are alternatives and limitations to this type of care. I understand that my health care provider or I can discontinue the telemedicine consultation/visit if it is felt that the videoconferencing connections are not adequate for the situation.
  • I understand that I may be released before all my medical problems are known or treated and it is my responsibility to make arrangements for follow-up care.
  • I understand that this is a faith based service, payment is neither asked for or expected.  
Name *
Name