Telehealth Consent Form

Name*

First NameMiddle NameLast Name

Date of Birth (DOB)*

Date

Gender assigned at birth*

MaleFemale

Gender identity

Ethnicity*

Email (Please note that your testing report will be sent to this email)*

example@example.com

Phone Number*

Please enter a valid phone number.

Address (Please note that the specimen collection box will be sent to this address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Positive Family/Personal history of cancer (Please answer this question in details and mention the age of diagnosis in all your answers)*

Insurance Company Name*

Insurance Plan #*

Policy #*

Policy Phone Number*

Upload Insurance Card Face*

Upload Insurance Card Back*

Upload ID front (e.g Driver license)*

Upload ID back (e.g Driver license)*

My Products

Telemedicine visit

$55.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Telemedicine Appointment prefered days.*

Telemedicine appointment prefered times. (The first available appointment will be scheduled to you and we will notify you through email)*

MorningAfternoon

1. I hereby authorize Medical and genetic diagnostics corp to use the telemedicine practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.

2. I understand that technical difficulties may occur before or during the telemedicine sessions and my appointment cannot be started or ended as intended.

3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

4. I agree that my medical records on telemedicine can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

5. I understand that my testing report will be sent to my email and the specimen collection box will be sent to my address, and I provided both of them correctly, and I accept any problem arise from providing wrong address or email.

Date*

Date

Signature*

Telemedicine Consent Form

Patient Information

Insurance Information (Will be used to bill for your genetic testing)

Telehealth Consent