Telemedicine Forms

Below is a short collection of general forms used in the delivery of telemedicine services.

Informed Consent / Confidentiality

• Consent To Treatment And Release Of Information
  c/o Kentucky Telecare, University of Kentucky Chandler Medical Center, Lexington, KY
  
  

• Consent To Participate In A Telemedicine Consultation
  c/o Marquette General Hospital Health System, Marquette, MI  
  
  

Evaluations

• Telemedicine Consultant Evaluation Form
  c/o Kentucky Telecare, University of Kentucky Chandler Medical Center, Lexington, KY
  
  

• Telemedicine Originator Evaluation Form
  c/o Kentucky Telecare, University of Kentucky Chandler Medical Center, Lexington, KY
  
  

• Telemedicine Patient Evaluation Form
  c/o Kentucky Telecare, University of Kentucky Chandler Medical Center, Lexington, KY