ElderConsult TeleMedicine Form
Please submit this form or the paper slip by September 15, 2022. If we do not hear back from you, we will assume you are staying with us and will bill you accordingly.
Will you continue with ElderConsult?
*
Yes, I’d like to continue with ElderConsult. I understand that visits with Dr Landsverk will be provided via telemedicine, with in-person services provided as necessary by associated physicians and nurses. I understand that the rates will be $250/month for on-call services and $375 per telemedicine session.
No, I choose to find my geriatric care services elsewhere. I understand that Dr Landsverk will no longer be able to provide any medical services for me after October 1, 2022.
Patient Name?
*
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Responsible Party Name
*
Responsible Party Signature
*
Submit
Should be Empty: