Consent to Telehealth Care

Please read through this Consent to Telehealth Care form before you request any of the services provided by Her Choice Women’s Clinic and our website at (under “Abortion Services,” “STD Treatment,” and “Family Planning/Gynecology Care”). At the beginning of each of our questionnaires, you will be asked if you accept the information in this form.

Consent To Telehealth Care

Health care through telehealth involves your health care professional using various forms of electronic communication, including audio, video, and questionnaires to interact or consult with you, or with other health care professionals working on your care. This may include discussing your medical information to educate, diagnose, follow-up a previous appointment, or use in therapy. Your medical history and health information may be discussed over video, audio, or another telecommunications method with you or another medical professional during telehealth care. Should a physical examination be necessary during telehealth care, then there may be photographs, audio, or video recordings taken to be used in your treatment in that session or the treatment in sessions that follow.

Your privacy and your health information will be protected during telehealth sessions by using both network and software security protocols. These protocols include protecting your data against corruption and exposure, whether intentional or unintentional.

Benefits of Telehealth Care You Can Expect

  • Increased convenience and better access to professional health care services, as you are able to receive care without the need to be in the same location at the same time as your health care provider.
  • Increased efficiency in your medical evaluations.
  • Increased access to the expertise of specialists, as you can speak with specialists who are far away where travel may have previously been a barrier to care.
  • Easier access to follow-up appointments and ongoing treatment with your health care professional.

Potential Risks of Telehealth Care to Be Aware Of

There are possible risks with any method of health care treatment, and there are possible risks to be aware of when using our telehealth care, including:

Failures in electronic equipment that can postpone medical evaluation and treatment;

The rare possibility of a failure in security, which would result in breaching the privacy or your medical information;

The rare possibility of your medical records not being fully accessed by your health care provider, which could cause errors in their judgment that lead to allergic reactions, adverse drug interactions, and other health issues.


I understand that if I’m experiencing a medical emergency, I should dial 911 or go to the emergency room of the nearest hospital. In a medical emergency, I should never use the telehealth services of Her Choice Women’s Clinic.

By consenting to this form, I, the patient, understand and agree to the following:

  • Her Choice Women’s Clinic cannot guarantee the results that you may expect from the listed benefits of telehealth care.
  • The privacy of your medical information is protected by state and federal laws, including when that information is gathered through telehealth care. This means that without your expressed authorization, any information that identifies you will not be provided to researchers or any other individual or organization.
  • At any point during my ongoing telehealth care, I retain the right to withhold or cancel my consent to the use of telehealth care.
  • As the patient I also have the right to review any and all information that is recorded throughout my telehealth sessions. I will be able to get copies of this information at a reasonable cost.
  • During my care, a range of different medical care methods may be open to me, which I can choose to take advantage of at any time. These other medical care methods have been fully explained to me by my Her Choice Women’s Clinic care provider.
  • During the course of telehealth care, my personal medical information may need to be communicated electronically to other health care professionals in different areas which may be outside of the state where I live.
  • If I have electronic communications with another health care provider about my care, it is up to me to inform my Her Choice Women’s Clinic provider of this.
  • I give my consent for my Her Choice Women’s Clinic provider to send me protected health information through SMS text messaging or email. I acknowledge that messages sent through these methods may not be fully secure in all instances.
  • I agree that when I input my address in the telehealth registration process, that I will be conducting all of my medical consultations, and if receiving abortion care, taking all medications prescribed to me while within the borders of the state in my given address.

By choosing to continue, I, the patient, hereby:

  • Acknowledge that I have spent the time to carefully read the entirety of this Consent to Telehealth Care form, and that I fully understand the expected benefits and possible risks of using telehealth care provided by Her Choice Women’s Clinic.
  • Consent to health care professionals employed or engaged by Her Choice Women’s Clinic using telehealth to provide my health care.
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