Personal Care Pediatrics, PA

By signing below, you consent to receive medical care either in person at our office or through telemedicine. Telemedicine includes healthcare services delivered through technologies such as video, telephone, or secure messaging.

Your healthcare provider and/or staff have explained how DOXIMITY video conferencing will be used for virtual visits. You will be able to connect once a video link has been sent to you.

I understand that there are potential risks associated with telemedicine, including technical issues, interruptions, and possible unauthorized access. I acknowledge that either my healthcare provider or I may choose to end the telemedicine visit if the DOXIMITY video connection is inadequate or unsafe for continued care. If needed, the provider may request that I come into the office for an in‑person evaluation.

I understand that if individuals other than my healthcare provider are present during the visit, they are required to maintain the confidentiality of all information shared. I will be informed of their presence and have the right to:

• Request that certain sensitive medical history or examination details be omitted.
• Ask non‑medical personnel to leave the room during the telemedicine visit.
• End the consultation at any time.

I understand that my insurance will be billed for the services provided, whether in person or via telemedicine. I am responsible for any remaining balance determined by my insurance plan, including copayments, deductibles, and/or coinsurance.

By signing this form, I certify that:

• I have read this form, or it has been read or explained to me.
• I fully understand its contents, including the risks and benefits of receiving care through in‑office or telemedicine services.