TeleHealth Request Form

Total Skin & Beauty Dermatology Center is now offering TeleHealth services for all of our patients. Consults will be conducted by phone or video conferencing, depending on the reason for your visit.

To schedule a Total Skin & Beauty TeleHealth appointment, please fill out the form below in its entirety.

Patient Name *

First

Last

Patient Date of Birth *

Patient Email *

Patient Phone Number *

Requested Appointment Date *

Specific Provider or First Available?

Reason For Appointment *

AM or PM Appointment *

Important information regarding your TeleHealth appointment. Please read and click ‘Submit’ below.

NATURE OF TELEHEALTH CONSULT: During the telehealth consultation :
1. Details of your medical history, examinations, x-rays, and test will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology.
2. A non-medical technician may be present in the telehealth studio to aid in the video/audio transmission.
3. Video, audio and/or photo recordings may be taken of you during the procedure(s) or service(s)
MEDICAL INFORMATION & RECORDS: All existing laws regarding your access to medical information and copies of your medical records apply to this telehealth consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telehealth interaction to researchers or other entities shall not occur without your consent.
CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth consultation, and all existing confidentiality protections under federal and Alabama state law apply to information disclosed during this telehealth consultation.
RIGHTS: You may withhold or withdraw consent to the telehealth consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
RISKS, CONSEQUENCES & BENEFITS: You have been advised of all the potential risks, consequences and benefits of telehealth. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telehealth consultation. All your questions have been answered, and you understand the written information provided above. Once your contact form has been submitted, our office will contact you to set up the appointment. Please be aware of the following in regards to telehealth visits:
1. A telehealth visit is not just a phone call, but will be billed to your insurance like any other office visit.
2. Our office will verify your telehealth benefits before scheduling. If your insurance requires a copay, we will collect the copay (via credit card) at the time the visit is scheduled.
3. In the event your insurance does not cover telehealth visits, you will be charged a flat rate visit fee of $50.

Accept Terms & Conditions *

I accept the Terms & Conditions and have read the above disclaimers. By checking this box, you are consenting to participate in a telehealth visit. Telehealth visits (audio, video or both) are billed in the same manner as in-person office visits. In the event your insurance does not cover telehealth services you will be responsible for paying a flat visit fee of $50.

Electronic Signature *