Patient Information

• Name:
• Date of Birth:
• Address:
• Phone Number:
• Email:

Purpo

The purpose of this consent form is to provide you with information about the Remote Patient Monitoring (RPM) program and to obtain your consent to participate. RPM involves the use of technology to monitor your health status remotely, including the collection and transmission of your vital signs and other relevant health data.

Description of the RPM Program

• You will be provided with a device to measure and transmit your vital signs to your healthcare provider.
• The RPM program aims to help manage your concussion by tracking your vital signs and providing timely interventions based on the data collected.
• Your healthcare provider will review the transmitted data periodically and may adjust your treatment plan as necessary.

Responsibilities

• Your Responsibilities:
  • Use the provided device regularly.
  • Ensure that your device is charged and connected to the transmission network.
  • Follow any instructions provided by your healthcare provider regarding medication, diet, and lifestyle changes.
  • Notify your healthcare provider of any changes in your health status, symptoms, or concerns.
• Healthcare Provider Responsibilities:
  • Review your transmitted data periodically.
  • Provide guidance and adjust your treatment plan as necessary based on the data.
  • Communicate any changes in your treatment plan to you promptly.

Consent to Participate

By signing this consent form, you acknowledge that:

• You understand the purpose and nature of the RPM program.
• You agree to participate in the RPM program and use the provided device as instructed.
• You understand that the RPM program is not a substitute for regular medical care and that you should continue to attend all scheduled appointments with your healthcare provider.