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Counseling and Education CenterNAFISA SECONDARY, PAY. D. Licensed Clinical Psychologist, PAY 23149 & AZ4243www.drsekandari.telemedicine INFORMED CONSENT FORM I hereby consent to engaging in telemedicine

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Begin by gathering all necessary information and documents.

02

Start by entering the patient's personal information, such as their name, address, date of birth, and contact information.

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Next, provide details about the patient's medical history, including any current medical conditions, allergies, medications, and previous surgeries or procedures.

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Include information about the patient's insurance coverage, including their insurance provider, policy number, and any applicable co-pays or deductibles.

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If applicable, document the reason for the patient's visit or the specific medical issue they are seeking help for.

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Who needs should a clinician use?

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Clinicians of various medical specialties, including doctors, nurses, physician assistants, and other healthcare professionals, may need to fill out a patient questionnaire or form to gather essential information.

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Patients who are seeking medical assistance or treatment from a clinician may also need to fill out a form to provide their medical history, current symptoms, and other relevant details.

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Insurance companies or healthcare organizations may also require clinicians to fill out specific forms to verify patient information, treatment plans, or authorize certain procedures or medications.

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