TELEMEDICINE CONSENT FORM

Our federal government has passed an emergency resolution authorizing Telemedicine visits during the Covid-19 pandemic. Many medical problems can be managed safely and efficiently with a Skype or phone conversation. During the pandemic this is the safest method for a visit for the patient and the Clinic Staff.

I understand and agree to the following:

• The registration and preparation of your chart are the same as an on-site visit.
• The visit will be record in your medical record labeled as a telemedicine visit.
• You may be required to come to the Clinic or directed to a laboratory for additional testing or examination.
• There is a charge for the visit: copay’s and deductibles will apply and be collected by on-line credit card payments.