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Telemental Health Consent

This is a telemental health consent form that provides your patients with their rights, benefits, risks, and further details and gathers their authorization.

Page 1

Please read and agree to the following terms and conditions before proceeding.

Email*

Patient Name*

Date of Birth*

Address*

Phone Number*

Emergency Contact Name*

Emergency Contact Phone Number*

Please describe the reason f...*

I have read and agree to the...*

I understand that telemental health services involve the use of electronic communications to enable health care providers to provide services to me from a remote location.

I understand that I have the right to withhold or withdraw my consent to the use of telemental health services at any time without affecting my right to future care or treatment.

I understand that there are risks and consequences of telemental health services, including, but not limited to, the possibility that services may be disrupted or distorted by technical failures, the transmission of my personal information may be interrupted by unauthorized persons, and/or the electronic storage of my personal information may be accessed by unauthorized persons.

I understand that I have the right to inspect all information obtained and recorded in the course of my telemental health services and may receive copies of this information for a reasonable fee.

Description:Use this Telemental Health Consent form to provide your patients with their rights, benefits, risks, and further details, and gather their authorization.

This Telemental Health Consent form is designed to ensure that your patients understand the nature of the telemental health services being provided, their rights and responsibilities, and the potential risks and benefits of these services. The form includes detailed information about the services, the qualifications of the providers, and the patient's rights to confidentiality and privacy. It also includes a section for the patient to provide their authorization for the services and to acknowledge their understanding of the information provided. By using this form, you can help ensure that your patients are fully informed and engaged in their telemental health care.

Full Name*

Date of Birth*

Address*

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Introduction*

Consent to Electronic Communication*

I agree to receive electronic communication from the healthcare provider.

Patient Name*

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Date*

Select date

Health Status*

I have not experienced any symptoms of COVID-19 in the past 14 days.

I have not been in close contact with anyone who has tested positive for COVID-19 in the past 14 days.

I have not traveled outside of the country in the past 14 days.

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I release and hold harmless the salon and its employees from any and all claims, demands, and causes of action arising out of or relating to any exposure to or infection by COVID-19.

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