Telehealth and Nutrition Counseling Consent Form

1. I authorize Sarah Kiel, RD, and Sarah Kiel Nutrition, LLC to allow me/the patient to participate in a telemedicine (videoconferencing and phone) service.

2. The type of service to be provided by via telemedicine is under the specialty of Nutrition Counseling and Coaching.

3. I understand that this service is not the same as a direct patient/healthcare provider visit because I/the patient will not be in the same room as the healthcare provider performing the service.

4. I understand that our sessions will be HIPAA-compliant to protect my healthcare privacy.

5. I understand this technology may include interruptions and/or technical difficulties depending on the connection between my internet service provider (ISP) and the company providing the internet service by my healthcare provider. I am aware that either my/the patient’s healthcare provider or I can discontinue the telemedicine service if we believe that the videoconferencing connections are not adequate for the situation.

6. I understand that the telemedicine session will not be audio or video recorded at any time.

7. I acknowledge that I have the right to request the following:

   • Omission of specific details of my/the patient’s medical history/physical examination that are personally sensitive, or

   • Termination of the service at any time.

8. It is the responsibility of the telemedicine provider, Sarah Kiel, RD, to conclude the service and terminate the videoconference connection.

9. My/the patient’s consent to participate in this telemedicine service shall remain in effect for the duration of the specific service identified above, or until I revoke my consent in writing.

10. I/the patient agree that there have been no guarantees or assurances made about the results of this healthcare service.

11. I confirm that I have read and fully understand this Telemedicine Consent Form. All blank spaces have been completed prior to signing.