By signing this form, I understand the following:
- I have been advised of the potential risks, consequences, and benefits of telemedicine
- I have had an opportunity to ask questions about the information presented on this form
- All my questions have been answered and I understand the information provided above.
My signature below (or other written acknowledgement of my acceptance to the terms above) indicates my consent to participate in a telemedicine appointment in connection with the service (s) described above. The consent will be documented in my medical record with FLORIDA MEDICAL CLINIC.