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Virtual Consultation Form





Informed Consent for Telemedicine Services
• I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider used to deliver services to an individual when he/she is located at a different location or site than I am.
• I understand that the telemedicine visit will be done through a two-way video link-up. The healthcare provider will be able to see my image on the screen and hear my voice. I will be able to hear and see the healthcare provider.
• I understand that the laws that protect privacy and the confidentiality of medical information including (HIPAA) also apply to telemedicine.
• I understand that I will be responsible for any copayments or coinsurances that apply to my telemedicine visit. However, if my insurance does not cover telehealth visits, I agree to pay $100 for the virtual appointment with my dermatologist.
• I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without effecting my right to future care or treatment.
• I understand that by submitting this form that I am consenting to receive health care services via telemedicine.

 

 

To ensure the safety of our patients & staff, our office will be offering Telemedicine appointments only until further notice. If you currently have an appointment scheduled over the next few weeks, our staff will be reaching out to you to reschedule or set up a Telemedicine appointment with Drs. Hooper & Jackson. If your needs are urgent, please call our office at 504-895-3376. For all other inquiries regarding refill requests, follow-ups, or other medical concerns, please send us a message through our patient portal or email us at frontdesk@audubondermatology.com . As always, we place the health and safety of our patients first & foremost. Our primary goal is to keep all of us healthy & safe. Sincerely, Drs. Hooper & Jackson
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