Sample Telemedicine -Form Fill

Section One
1.1

Patient Name

First Name
1.2

Patient Name

Last Name
1.3

Date of Birth

Date
/
/
/
/
1.4

Name if signed by other than the patient

First Name
1.5

Name if signed by other than the patient

Last Name
1.6

Relationship to the patient
1.7

Date

Date
/
/
/
/
1.8

Signature
1.9

Witness Name

First Name
1.10

Witness Name

Last Name
1.11

Witness Signature