telemedicine-consent-form – aedoctors

Tina Bansal, MD
800 E Woodfield Rd, Ste 113. Schaumburg, IL 60173
Phone: 847-686-6866 Fax: 847-706-9891

Telemedicine Visit Consent Form

Due to the pandemic, Advanced Endocrinology offers audio and/or video televisits as needed.

I, Date of Birth(MM-DD-YYYY):, consent to be evaluated for visits both in person and telemedicine. I understand that I am ultimately responsible for any charges not covered by my insurance and if I do not have insurance am responsible for the full cost of the visit. If the appointment is missed or cancelled less than 24 hours in advance, then I understand that I will be responsible for the no showfee charged to my account. I am aware that if I do not provide consent that I will be unable to utilize the telemedicine option offered by Advanced Endocrinology.

Patient Signature: