Telehealth Release Form

Please provide the required information below.

Patient Information

Name

Date of Birth

Email

Phone number

Medical Information

Diagnosis

What has the patient been diagnosed with?

Symptoms

What are symptoms the patient experienced?

Is the patient currently experiencing any symptoms?

Comments

Is the patient recovered enough to be released?

Date and Time of Release

Terms and Conditions

By signing this form, I consent to the secure exchange of my medical information regarding my treatment through telehealth services. All information shared during these sessions will be kept confidential and protected under HIPAA and other applicable privacy laws.

I acknowledge that I have received the necessary telehealth services and consent to being released from further telehealth treatment. I understand that any ongoing medical needs may require follow-up care or in-person visits.

I confirm that I have discussed my treatment plan and have received the necessary care through telehealth. I acknowledge that I have been informed about my condition and any follow-up care required.

Patient

Name:

Date:

Doctor

Name:

Date:

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