TeleHealth Consent Form

    TeleHealth Consent Form


    Purpose: The purpose of this form is to obtain your consent to participate in a Telehealth Consultation/Treatment in connection with the following procedure(s) and/or service(s)

    1. Nature of Telehealth Consult: During the telehealth consultation:
    a. With Telehealth, details of your medical history, examinations, x-rays, and tests will be discussed with other health care professionals through the use of interactive video, audio and telecommunication technology.
    b. A digital physical examination may take place.
    c. During the telehealth consultation your physical therapist will possibly discuss the results of your previous examination, recent changes to your health status and/or previous treatment, and will be able to answer questions you have about your current symptoms and strategies to self-manage/self-treat those symptoms. The physical therapist will also be able to provide education and make recommendations about home exercise and provide home exercise progression.
    d. A non-medical technician may be present in the telehealth studio to aid in the video transmission.
    e. Video, audio and/or photo recording may be taken of you during the procedure(s) or service(s).

    2. Medical Information & Records:
    All existing laws regarding your access to medical information and copies of your medical records apply to this telehealth consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient identifiable images or information for this telehealth interaction to any other parties or entities shall not occur without your consent.

    3. Confidentiality:
    Reasonable and appropriate efforts have been made to eliminate any confidential risks associated with telehealth consultation, and all existing confidentiality protections under state and federal law apply to information disclosed during this telehealth consultation.

    4. Rights:
    You may withhold or withdraw your consent to the telehealth consultation at any time without affecting your right to future care or treatment.

    5. Risks, Consequences & Benefits:
    You have been advised of all the potential risks, consequences and benefits of telehealth. Your health care provider has discussed with you the information provided above.

    I agree to participate in Kinect Physical Therapy Care for the procedure(s) and/or service(s) above.

    By Entering Your Name, This Will Service As Your Digital Signature





    Patient Preparation for Telehealth Visit 

    We are excited to offer you another option to compliment direct Physical Therapy care in helping you find the best way to optimize your physical health and quality of life during this time. This form is designed to help you prepare in advance of your Physical Therapy Telehealth visit in order to optimize our time together. Below you will find guidance in 3 sections to help you find the right environment, focus, and mindset to achieve the best results from the visit.

    SECTION I: Environmental Preparations
    SECTION II: Content Preparations
    SECTION III: Mindset Preparations



    SECTION I: Environmental Preparations
    (Set Up)
    • Consider a room or area that affords you a privacy level you are comfortable with and minimal distractions.
    • You can use any device that supports videoconferencing. We will send you an invite through You do not have to download anything. This platform of videoconferencing is HIPPA compliant.
    • suggests that you use Google Chrome or Firefox for best web browsing efficiency. Others have used Safari without difficulty.
    • The room/floor space should allow you enough room to move around freely and exercise.
    • Consider how you will position your device to allow your therapist to observe and evaluate how you are moving/exercising.
    • Laptops or desktops with cameras/microphones have the best capacity and video If you would like to move around to different areas of your home, a laptop works best.
    • Lighting: should be in front of the device shining on you vs behind you (ie., window). Shadows may make it harder to see specific regions of the body, so front lighting is ideal.
    • Please spend some time identifying your goals, whether you have been having any symptoms, and what specific activities you are having trouble with. We have the opportunity to see you in your home environment and truly replicate and give guidance to those activities – let’s take advantage of it!
    • Have any equipment that you use to exercise, or that has been given to you for your home exercises readily available for us to view and evaluate.
    • Have any desks, chairs, beds, ready for us to evaluate and determine if they can be modified if contributing to your symptoms. If you think our session might take us around your home, have a few areas in mind where you can place your laptop or device.
    • Consider wearing flexible clothing like you normally wear during your treatments in the clinic. It should allow you to move freely, while at the same time, allow for visual access to your areas of concern.
    • All patients, male and female, need to ensure the therapist can visually observe the area of your body that is symptomatic or contributing to your symptoms. Please chose your clothing appropriately, allowing us to observe alignment and position. NOTE: Baggy clothing or clothing that excessively covers the trunk may not provide an optimum visual assessment. At all times, however, only present yourself in a manner in which you feel is appropriate and comfortable. At no point will the session be recorded on our end.
    • Consider either being barefoot or determine prior to our session which shoes you may be wearing while exercising. Consider what type of flooring you will be standing on for firmness and traction. You may want to have a yoga mat option.
    SECTION II: Content Preparations

    NOTE: A goal is best established in light of the follow up question: “How would I know if I achieved my goal?” It is not simply the elimination of symptoms, but also the ability to move or function more freely, more independently, to sleep more restfully, to not feel distracted by your symptoms.


    Session Goals:

    Identify your top 2-3 priorities for your session. The following list is a suggested guide:

    1. A. Pain or Symptom relief: Your therapist may guide you through questions that are a bit more extensive in description/detail in order to best understand your concerns without being able to physically touch the problem.
    2. Exercise progression.
    3. Posture/Movement education (body mechanics, ergonomics, activity based problems).
    4. Mobility/Flexibility.
    5. Relaxation/Strategies to promote rest into an area of discomfort and the use of breathing and Awareness exercises.
    6. Other:

    Know that it may take longer than you expect to address each issue within our virtual session. We will prioritize your goals at the beginning and pace ourselves to address each goal.

    SECTION III: Mindset Preparations

    If you have issues or burdens that you believe are important to discuss with your PT feel free to initiate those discussions. We understand that during these challenging and emotional times you may need to share some of your challenges. Speaking with someone who is willing to listen and offer a non-judgmental, but discerning point of view, can help with healing and perspective. As such, please feel free to share as much as you feel comfortable with at the opening and/or closing of each session. These are rich ways in which we can stay connected. Examples include:

    • Sharing a challenging moment in the week or day.
    • Sharing a nice win.
    • Sharing a perspective that has helped you or your family.
    • Sharing a family saying, a pearl of wisdom, a spiritual.

    Thank you for taking the time to help us support you!

    The Team at Kinect Physical Therapy