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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Please go to www.transformativefx.com for more information on how to use our telehealth system and ZOOM. You may also go there to "check-in" if you forget the Meeting ID below.
(It is the exact same as our office number).

Our system & ZOOM will work on all smart phones, tablets and PCs via the installation of the ZOOM app.

Download and Install ZOOM
(Registration is optional but, provides more customization and options for you)
https://zoom.us/download
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To “check-in” prior to your appointment:

1) Open the ZOOM app and use Meeting ID: 660 530 3086

** You may also use the link: https://zoom.us/j/6605303086

2) You are now in your provider's waiting room. Wait for your provider to start the call.

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Email address *
Clinician *
Select the clinician you are filling this out for
Name of Patient *
Full legal name of patient seeing provider
Your answer
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.
Your answer
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.***
Your answer
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.***
Your answer
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.
Your answer
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