Telehealth Request and Consent

Form
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.
Please list a brief description of your problem.
Name

First Name Last Name
Email *
example@example.com
Cell Phone Number *

Area Code Phone Number
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

Clear
Should be Empty:

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