Pain 2 Wellness Chiropractic Center, LLC
and/or
Brain & Bodily Injury Centers (BaBIC)
3910 Cascade Road SW, Atlanta, GA 30331
Website: www.Pain2Wellness.com | www.BBInjury.com
Purpose and Nature of Telemedicine
Telemedicine involves the use of electronic communications (audio, video, or data) to enable healthcare providers to
share medical information for diagnosis, consultation, treatment, or education. It allows you to receive care through
secure, HIPAA-compliant video conferencing platforms.
Benefits
• Convenient access to healthcare services without travel
• Improved continuity of care and access to specialists
• More efficient evaluation and management of care
Possible Risks
There are potential risks associated with telemedicine, including technical failures, unauthorized access, or
incomplete data transmission. Reasonable efforts are made to minimize these risks through encryption and secure
systems.
Patient Rights
• You may withhold or withdraw consent at any time without affecting future care.
• You may request an in-person visit at any time.
• You have the right to privacy and confidentiality under HIPAA and Georgia law.
• You will be informed of all personnel present and their roles.
Financial Responsibility
You understand that you are responsible for all telemedicine charges as agreed upon with your insurance company,
attorney, or self-pay arrangement.
Emergency Protocol
Telemedicine is not an emergency service. In case of an emergency, call 911 or go to the nearest emergency
department.
Consent to Participate
By signing below, you acknowledge that you have read and understood this consent form. You agree to participate in
telemedicine consultations with Pain 2 Wellness Center and/or Brain & Bodily Injury Centers. You acknowledge that
no guarantees or assurances have been made regarding treatment outcomes.
Patient Name: _______________________________
Date of Birth: _______________________________
Address: _______________________________
City, State, Zip: _______________________________
Phone: _______________________________
Email: _______________________________
Patient/Guardian Signature: _______________________________
Date: _______________________________
Notice: This form complies with the Georgia Telehealth Act (O.C.G.A. § 33-24-56.4) and HIPAA Privacy and
Security Rules.
Telemedicine services are subject to the same standard of care as in-person visits.
TeleHealth Patient Consent Form
