PATIENT CONSENT TO THE USE OF TELEMEDICINE

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.A copy of this form will be available in your documents.

Every effort to provide prescriptions in the most timely manner will be made.

I hereby authorize MBW, PLLC to use telemedicine in the course of my diagnosis and treatment.

This also may mean that it is possible that I might be responsible for full payment of my medical expenses until the insurance reimbursement comes through to the practice