Consent for Telehealth Services

Complete Foot and Ankle Specialists, LLC | (937) 599.3668 | (937) 322.3346

Please correct the errors described below.
  1. I hereby authorize Complete Foot and Ankle Specialists to use the telehealth practice platform for Telemedicine/Videoconferencing sessions for evaluating and diagnosing my medical condition.
  2. I understand no information will be stored with any third-party platform other than the electronic medical record system already used by our practice.
  3. I understand that technical difficulties may occur before or during the telehealth sessions which may affect my appointment, causing it to not start or end as intended.
  4. I agree my physician can contact me via an interactive video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
  5. I understand telehealth visit charges are billed and collected in the same manner as for regular in-office visits.

Please answer the following questions:

You will get a link before the appointment which will take you directly to the virtual waiting room and your physician will connect with you once we see you there.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.