Healthcare Kiosk Agreement

HEALTHCARE KIOSK AGREEMENT

Facility Name:    Location / Kiosk ID:

Patient Information

Date of Birth:    Gender (check one): Male Female Other

Insurance Information

Medical History (Brief)

Kiosk Use Authorization

Purpose: I authorize the facility to use automated kiosk equipment to collect personal and health information for intake, vitals capture, identification verification, and insurance processing. Kiosk interactions may include the capture of images of identification and insurance cards, vital signs, and limited biometric identifiers necessary for device operation. I understand that the information collected will be used for treatment, payment, and healthcare operations as described below.

I specifically authorize the kiosk to collect (check all that apply):
Vital signs (blood pressure, pulse, weight, temperature)
Photographic capture of identification and insurance cards
Biometric identifiers for authentication (face scan, fingerprint)
Audio recording (for guided instructions)

Retention and Access: Information collected by the kiosk will be stored in the facility's electronic records for purposes of clinical care and administrative use. Retention period: . Access to kiosk data is limited to authorized personnel. I understand I may request review or amendment of kiosk-captured information in accordance with facility policies.

Privacy, Use and Disclosure

Privacy: The facility will safeguard information collected by the kiosk in a manner consistent with applicable privacy laws. By signing this Agreement I acknowledge receipt of a privacy notice describing permitted uses and disclosures. I authorize the facility to use and disclose kiosk-collected information to other treating providers, insurers, payors, and business associates as necessary for my care and for payment and healthcare operations.

Electronic Communications: I consent to receive electronic communications related to my care, including electronic messages and system-generated notifications. I understand that messages sent through the kiosk or by email/SMS may not be encrypted and accept the inherent risks.
Acknowledgment of Privacy Notice: I acknowledge receipt of the facility's privacy notice.

Risks, Limitations and Responsibilities

Risks and Limitations: I understand that kiosk equipment is automated and may produce errors, inaccurate readings, or capture images that are unclear. The kiosk is not a substitute for clinical judgment. I agree to notify facility staff of any discrepancy between kiosk-collected information and my actual health status. The facility does not guarantee uninterrupted or error-free operation of kiosks.

Patient Responsibilities: I will follow posted instructions for kiosk use, verify my information for accuracy, and promptly report problems or concerns to facility staff. I am responsible for securing personal items while using the kiosk and for verifying that photographs or documents scanned are accurate prior to completion.

Release, Indemnity and Limitation of Liability

Release: To the fullest extent permitted by law, I release the facility, its officers, employees, agents, and contractors from liability for incidental loss or damage arising from the use or malfunction of kiosk equipment, except for willful misconduct or gross negligence.

Indemnity: I agree to indemnify and hold harmless the facility from third-party claims arising from my misuse of the kiosk or from false or fraudulent information I provide through the kiosk, except to the extent such claims arise from the facility's gross negligence or willful misconduct.

Acknowledgments and Certifications

By signing below I certify that:

The information I provide via the kiosk is true and accurate to the best of my knowledge.

I understand the risks and limitations of kiosk-collected data and accept responsibility to confirm critical information with facility staff.

I authorize facility staff to access and use kiosk-captured information for my care, billing, and related operations.

Revocation: I understand I may revoke this authorization at any time by providing written notice to the facility, except to the extent that the facility has already acted in reliance on this authorization. Revocation will not affect uses or disclosures made prior to revocation.

Authorization Expiration Date: This authorization will expire on unless an earlier date or event is specified.

Special Notices

Photographs and Biometric Data: Where photograph or biometric capture is authorized, such data will be used only to authenticate identity, prevent duplicate records, and support clinical safety processes. The facility will not use biometric data for secondary purposes without separate authorization.

Minors and Legal Guardians: If the patient is a minor or otherwise legally incapable of giving informed consent, a parent or legal guardian must sign below and provide their relationship to the patient.

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