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*
(For example, enter "0" for no one, "1" for a spouse, "2" for parents, etc.)

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:

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Relationship to Patient (if other than patient):