Sweetwater Pediatrics
I [Entered Child's Name Above] agree to receive this health care service. I understand that the health care provider, Dr. Yeshlur, is located in another location, Sweetwater Pediatrics 1101 Gateway Blvd Rock Springs WY. A Telehealth service means that my visit with a practitioner at the distance site will happen by using special audiovisual equipment. This consent is valid for 1 year for follow-up telehealth services with the health care provider.
I also understand that:
I have read this document carefully and my questions have been answered to my satisfaction.
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.
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.
Facility Name: Sweetwater Pediatrics
Facility Address: 1101 Gateway Blvd Rock Springs Wy
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