Consent for Audio/Video Recording

I do give my consent to be AUDIO/VIDEO recorded during any in office or telemedicine appointment. I do NOT give my consent to be AUDIO/VIDEO recorded during any in office or telemedicine appointment.

DISCLAIMER: 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 document.

Signature of Patient:

Date:

Signature of Parent, Legal Guardian or Conservator:

Date:

Signature of Witness (if appropriate):

Date:

Your information will be encrypted.