Telehealth STD Testing Consent Form

Patient Information

Full Name Date of Birth Phone Number Email Address

Telehealth Consent

I understand that STD testing will be performed via telehealth services.

I acknowledge that my privacy will be protected and information kept confidential to the extent required by law.

I have been informed about the risks, benefits, and alternatives to telehealth STD testing.

Testing Authorization

I consent to the collection, testing, and disclosure of my samples for STD testing purposes.

Questions/Comments

If you have any questions or comments, please write them here:

Patient Signature

Signature Date