Consent for Doxy.me Telehealth
In an emergency, call 911 or go to your nearest emergency room. Telemedicine is not appropriate for emergencies and this form is not monitored continuously.
Patient Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Consent
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I give consent to use DOXY.ME, contacted via email, to facilitate a telehealth appointment with Dr. Smita H. Patel, M.D. for psychiatric evaluation and treatment.
Dr. Smita Patel offers licensed telemedicine psychiatric services to patients residing in the District of Columbia, Maryland, and Florida.
Signature
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Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
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