Louetta Pediatrics, PLLC

Available Forms

Consent and Agreement for Telemedicine Consentimientos y Acuerdo de Telemedicina

Consent and Agreement for Telemedicine

Patient Information

Patient Name *

Patient DOB *

Parent/Guardian Information

Your Name *

Your DOB *

Relationship to Patient *

Relationship to patient if not listed.

Phone Number *

Insurance Information

Insurance Company

ID #

Group #

Effective Date

Address

Policy Holder

DOB

General Consent for Telemedicine Services

I understand that by checking the boxes, I am agreeing to the terms and conditions.*

I am the parent/guardian of patient above. I agree to participate in a telemedicine evaluation. I understand that I can withdraw my permission anytime. I understand that if I do not chose to participate in a telemedicine session I will pursue face to face consult.

I give consent for the patient who may be defined as my child or a child who I have legal responsibility, to receive care and treatment at Louetta Pediatrics, PLLC through Telemedicine Services. I authorize the electronic transmission of the patient's medical information (including medical records, photos, notes) for evaluation, diagnosis, treatment and billing. I am aware that the same confidentiality information security practices apply.

I understand that a telemedicine service requires an appointment and that telemedicine services hours follow the regular clinic hours. I understand I would have to call the clinic (281-826-0016) for urgent medical questions or needs. Louetta Pediatrics' staff do not monitor this site for urgent questions or concerns.

I understand that telemedicine services have limitations and that the patient may have to come in for a face to face examination, for lab work or other diagnostic tests. I acknowledge that the Louetta Pediatrics' provider cannot be held liable for advice, recommendations and/or decisions based on factors not within their control: inability to visualize well or listen to body parts, distortions of images that may result from electronic transmission, or incomplete/inaccurate data provided by patients/parents/guardians and etc.

I understand that in choosing to participate in telemedicine, some parts of the exam may involve physical tests conducted by the individuals at my/my child's location at the direction of the telemedicine healthcare provider.

I understand that telemedicine services may be limited or unavailable as a result of technological or equipment failures. I understand that it may be necessary for others to be present during the visit other than my child's healthcare team and provider in order to operate the video equipment. These individuals are bound to maintain confidentiality of all information obtained. I understand that there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that either the Louetta Pediatrics provider or I can discontinue my/my child's telemedicine visit if it is felt that the video connection is not adequate for the situation.

I understand that each child/patient requires a separate telemedicine call and appointment. The Louetta Pediatrics healthcare provider cannot address the next patient's concerns until after the first appointment ends and a new a new call starts. I understand that by doing this, each call's notes and pictures are filed under the patient's medical record.

* Required field