Consent for Telemedicine

Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I give consent to use Doxy.me to facilitate Televisit with Dr. Smita Patel, M.D. for psychiatric evaluation and treatment. The Telemedicine services were initiated due to nation wide emergency.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: