Adolescent Telehealth Parental Consent Form

Adolescent Information

Adolescent Name Date of Birth

Parent / Legal Guardian Information

Name of Parent/Legal Guardian Relationship to Adolescent Contact Phone Contact Email

Consent

I, the parent/legal guardian named above, give my consent for my adolescent to participate in telehealth services. I understand the nature and purpose of telehealth, as well as its potential risks and benefits.

Additional Comments

Signature

Provider Information

Provider Name Provider Contact