Consent form (please read before)

Note: please read the consent form below. After scheduling a Televisit, you will receive a Telemed Confirmation email and text with a link to the "waiting room." There, you can enter vitals and sign the digital form before the appointment. If your appointment is via Doxy.me or telephone, please read the consent form and give your verbal consent to the provider. Thanks!

Consent for Telehealth Services

Callie Pediatrics, PC

6636 E Carondelet Drive, Tucson, AZ 85710

Televisits allow parents/caregivers and teen patients over 18 in remote (especially home) locations to access our Providers quickly, efficiently and without travel or risk of exposure. After a Televisit appointment is scheduled, you will receive an email and text (SMS) Telemed Confirmation with a link to the virtual “waiting room.” Please make sure we have your current and correct contact information. Instructions forTelevisits has been provided here.

1. I understand that my health care provider at Callie Pediatrics 6636 E Carondelet Drive, Tucson, AZ 85710 wishes to engage in a telehealth visit or series of visits. I understand that these encounters will not be the same as a direct patient/health care provider visit because I will not be in the same room as my health care provider. Instead, we will communicate using two-way simultaneous audio-visual technology. I understand that after I schedule the Televisit, I will receive an email and SMS text Telemed confirmation link to the email/text we have on record.

2. I understand that I have the right to refuse to participate in any telehealth encounter at any time or to end it at any point during the encounter. I understand that if I do not wish to participate in a telehealth encounter I will need to either make an appointment for an in-person visit with my provider or seek care at the closest emergency room if I believe that my symptoms warrant that level of care. I further understand that my provider may not be able to accommodate an in-person visit and there may be a delay in my care if I choose an in-person visit.

3. I understand that my health care provider can discontinue the telehealth encounter if he or she believes that this technology does not meet the standard of care necessary to address my medical concerns. If that happens, I understand that I will need to either make an appointment for an in-person visit with my provider or seek care at the closest emergency room if I believe that my symptoms warrant that level of care.

4. I understand how the technology will be used to conduct any telehealth encounters with this practice. I also understand that, with this technology, there is a risk of interruption and technical difficulties.

5. I have had the opportunity to ask questions about telehealth encounters and the technology. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language that I understand.

6. I understand that I will be told the identity of everybody who will be in the room with my health care provider during any telehealth encounter and that those people will be present only because my health care provider has determined that their presence is necessary to assist in my medical treatment according to the applicable standard of medical care.

7. I have been told whether my provider is licensed to provide medical care in the state where I am located. If they are not licensed in the state where I am located, I consent to receive telehealth services anyway because the provider is fully licensed in the state where they are located.

8. I understand that I will be responsible for any co-pays and coinsurance that apply to my telehealth encounter(s).

9. This consent will remain valid for six months from the date of my first telehealth visit with Callie Pediatrics.

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Patient/Parent/Guardian signature Date