Telehealth Request and Consent

Request for Telehealth Visit and Consent to Treat

I am requesting a telehealth visit and give permission for the doctors of Miller Vision Specialties to the treat me through an online platform.

Send picture of insurance card to appointments.miller2020@gmail.com or fax to 336-545-1931.

Please list a brief description of your problem.

Name

First Name Last Name

Email *

example@example.com

Cell Phone Number *

Area Code Phone Number

ABN notice. All charges are patient responsibility if insurance does not pay. Type your name below. *

Choose device platform. Iphone (Facetime App) or Android ( Duo App) Please make sure you have the app downloaded to your device prior to telehealth appointment. *

Signature

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