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Telehealth Patient -Form Fill

Section One
Q1

Patient Name

First Name
Q2

Patient Name

Last Name
Q3

Phone Number

Phone Number
Q4

Email
Q5

Birth of Date

Date
Q7

Medical ID
Q8

I sign this consent form on the behalf of
Q9

Your Name

First Name
Q10

Your Name

Last Name
Q11

What is your relationship with this person?
Q12

Date of Sign

Date
Q13

Signature
Q14

Health Care Professional Name

First Name
Q15

Health Care Professional Name

Last Name