Please provide the cell phone number of the phone that you'd like to use for the video call.
You will receive a link via text message at the time of your appointment.
Please enable speakers, microphone, and camera before the appointment.
If you have images such as rash, or swelling that will be helpful to the doctor, please email in advance to firstname.lastname@example.org.
You will he asked to verily that you have read and agree to the following:
1. I acknowledge that I have requested to schedule a telehealth appointment with a provider at MD at Mount Pleasant Pediatrics.
2. I understand that I will be connected via videoconferencing, video images, photo images, or telephone conference.
3. I understand there are potential problems with this technology, including interruptions, unauthorized access and technical difficulties. I understand that my doctor or I can discontinue the telehealth appointment if it is felt that the videoconferencing connections are not adequate for the situation. I understand that I can discontinue the telehealth appointment at any time.
4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.
5. I have had the alternatives to a telehealth appointment explained to me, and in choosing to participate, I understand that some parts of the exam involving physical tests may need to be conducted by individuals at my location at the direction of the provider.
6. In an emergency situation, I understand that the responsibility of the telehealth provider may be to direct me to emergency medical services, such as an emergency room. The telehealth provider’s responsibility will end upon the termination of the telehealth connection.
7. I understand that billing for the telehealth consultation will occur from Mount Pleasant Pediatrics. My insurance will be billed, and I will be responsible for any copays, deductibles, and non-covered services. If my insurance does not cover telehealth visits, I agree to be responsible for the full amount charged.
8. I have read this document carefully, and understand the risks and benefits of the telehealth appointment and have had my questions regarding the process explained.