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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.



    We are grateful to be back in the office serving our patients. We continue offering the highest standards of cleanliness, safety and sanitation including: Prescreening phone calls prior to appointments, temperature checks and screening upon arrival, and seeing patients on a limited basis only to minimize occupancy.

    The safety of our patients and staff continues to be a top priority. Please call us at 504-895-3376 to schedule an appointment today.