I consent to have my child’s visit conducted by telehealth medicine with the Pediatric Effective Elimination Program Clinic & Consulting, PC, known as the PEEP Clinic in the remainder of this consent.
If this is my child’s first visit, I certify that my child has had a complete physical exam, including genitalia, during a well child visit with their primary care provider in the last 12 months that was normal.
I understand that PEEP Clinic uses a HIPPA compliant platform to conduct my child’s visit and all applicable confidentiality practices shall apply to the telehealth services. Furthermore, I understand that I take full responsibility for the location at which I choose to have the visit and any breach of confidentiality that may happen in my chosen location.
I understand that audio and video recording of telehealth visits is NOT PERMITTED by law.
I understand that the late cancellation and no show policies apply to telehealth visits. If you “DECLINE” your scheduled virtual visit it will be billed as a no show appointment.
I may refuse telehealth services for my child at any time.
The patient shall have access to all medical information from the services, under state law [C. R. S. 2018, 25.5-5- 320 (4)]