Consent for Telemedicine
Please complete this form to provide your consent for telemedicine services with Dr. Smita Patel.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Telemedicine Consent Statement
*
I give consent to use Doxy.me to facilitate Televisit with Dr. Smita Patel for psychiatric evaluation and treatment.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: