Patient forms to complete prior to visit.

Please read and check the box for each form then sign at the bottom. These forms will need to be completed prior to your Telehealth visit.

1. Patient Acknowledgement and Consent

Download the form in:

I have read and agree to the Patient Acknowledgment and Consent form

2. Authorization to Release Medical Information

Download the form in:

I have read and agree to the Authorization to Release Medical Information form

3. Blue Button Packet Telephonic Visits

Download the form in:

I have received and understand Medicare's Blue Button information

First Name

Last Name

Email Address

Phone Number

State

Type your name to sign

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