Pediatric Telehealth Consent Form

Please read and complete the following consent form to participate in telehealth services for your child.

Patient Information

Child's Full Name Date of Birth Parent/Guardian Name Relationship to Patient Contact Number

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Consent & Acknowledgment

I understand that telehealth involves the use of electronic communications to provide healthcare services to my child. I have been informed of the potential risks and benefits.

I understand that all laws protecting privacy and confidentiality of medical information also apply to telehealth.

Questions or Concerns (Optional)

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Signature of Parent/Guardian Date