Telehealth Consent Form

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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)]

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