Tele‑Ophthalmology Consent Form


I understand that tele-medicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual who is located at a different site to the provider; and I consent to receiving health care services from Dr Erwin Groeneveld by telemedicine.

I understand that laws protecting privacy and confidentiality of medical information apply to telemedicine. I understand that I will be responsible for fees and co-payments that are applied to my telemedicine visit.

I understand I have the right to withhold or withdraw by consent to the use of telemedicine in the course of my care at any time without jeopardising my right to future care or treatment.

Furthermore, I understand there are potential risks to this technology, including interruptions, and authorised access and technical difficulties. I understand that my healthcare information may be shared with individuals for scheduling or billing purposes and that those individuals are subject to confidentiality agreements. The alternatives to telemedicine consultation have been explained.

During the telemedicine consultation details of my medical history, examinations, investigations and results of tests may be discussed using interactive video, audio and telecommunications technology. Video, audio and/or digital photography may be recorded during the telemedicine consultation visit.

All reasonable efforts will be made to protect my confidentiality and all existing confidentiality and privacy protections under Federal and State law apply to information disclosed during the telemedicine consultation.

In most respects my telemedicine consultation will be similar to a routine medical office visit with the omission of detailed clinical examination and sophisticated testing.


I have been advised of all the potential risks, consequences and benefits of telemedicine. My healthcare practitioner has discussed to me the information provided above. I have had an opportunity to ask questions about this information and all my questions have been answered. I understand the written information provided above.


, acknowledge that I have read and understand the content within this form.