Consent for Telemedicine Visit

Consent for Telemedicine Visit

Non-Provision of Documentation, Notice of Single Issue of Prescriptions, Request for Additional Fees for Prolonged Management. Please complete this contract and submit.

"*" indicates required fields

I agree to conduct this visit via using either an unsecure phone line or phone video call and verified that I am/represent the patient listed below, using two identifiers

I confirm that my physical location as:

Address*

Dr. Gudel is physically located in Alabama providing this service from Birmingham, AL.

Dr. Gudel has discussed the limitations of evaluation and management by telemedicine and the availability of in-person appointments. I verify that I understand these limitations and wish to proceed. I agree to call back or seek an in-person evaluation if the symptoms worsen or if the condition fails to improve as anticipated.

I understand that no documentation will be provided to submit to insurance, however Pinwheel will issue a receipt clearly marked for “medical services” which can be submitted to HSAs and/or tax purposes.

I understand that medications will be called in one time only. Dr. Gudel will not price-shop for patients, and patients may request that prescriptions be held until a suitable pharmacy is found.

If prolonged care and/or documentation is required, the patient may be asked to purchase additional time slots.

Executed on:

MM slash DD slash YYYY
Time*
:

By:

Name*

Relationship to Patient (if other than patient):