Telehealth Informed Consent & Contact Information
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###THIS FORM MUST BE FILLED OUT BY AN ADULT###

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--= Appointments will still follow your normal scheduled times =--
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Email *
Clinician *
Select the clinician you are filling this out for
Name of Patient *
Full legal name of patient seeing provider
Date of Birth (Patient) *
Date of birth of patient
MM
/
DD
/
YYYY
Phone Number (Guardian) *
Phone number of "Guardian" if patient is under 18. Phone number of "Self" if 18 or older.
ZOOM PMI (Patient)
ZOOM Personal Meeting ID (PMI) of patient. ***This is not required and only applicable if you have a registered account with ZOOM.***
ZOOM - Email Used (Patient)
Email used to register and login with ZOOM for the patient. We can use this to confirm contact requests within ZOOM and also provides a way to securely message your provider outside of normal hours. ***This is not required and only applicable if you have a registered account with ZOOM.***
Method of contact Information if ZOOM is unavailable
Please provide us with a direct number to the patient if our telehealth system is down or unable to serve you.
Phone Number (For Contact) *
Telephone number for your provider to call directly for telehealth sessions if needed.
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