By signing this form,
I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.
I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures.
I understand that I can be charged the additional fees that my insurance does not cover.
I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.
Providing the best possible care to every patient is our primary goal. The only way we can meet this goal is if we work together in parent/professional partnership for the best interest of your child!
PATIENT’S CAREGIVER RESPONSIBILITIES:
DOCTOR’S/ HEALTHCARE PROVIDER’S RESPONSIBILITIES:
ARRIVAL TIME, AND LATE POLICY:
INSURANCE AND PAYMENTS:
If you feel that your child is having a life-threatening medical emergency, please go to the nearest hospital or call 911, if your child is in distress.