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General Consent Form Financial Consent Form

Welcome to the Patient Forms page of Call Doctor Packer Telemedicine.

There are two required forms that must be completed electronically as part of your patient intake and before your appointment is confirmed.

  •  General Consent to Treat Form and Agreement

    By entering your full name in the contact form, you acknowledge that your name serves as a digital signature and holds the same legal value as a handwritten signature.
    This confirms that all the information you have provided is accurate and that you agree to the terms outlined in our Patient Policies.
    Your name will be used to process your records, consent, and any necessary medical documentation.

    1. General Consent to Treat Form

    2. Financial Consent Form

    Please complete and electronically submit both forms. The General Consent to Treat Form is the first form and appears on this page to the right.
    After completing the General Consent to Treat Form, please follow the instructions on this page to access and complete the Financial Consent Form.
    Completing both forms in advance helps us prepare for your visit and streamline your appointment and check-in process.

  • Submit Your Forms

    By entering your full name in the contact form, you acknowledge that your name serves as a digital signature and holds the same legal value as a handwritten signature. This confirms that all the information you have provided is accurate, and you agree to the terms outlined in our Patient Policies. Your name will be used to process your records, consent, and any
    necessary medical documentation.

    Financial Consent Form

    The Financial Consent Form is the second required form. After completing your General Consent to Treat Form, please click the button below to complete and electronically submit your Financial Consent Form.
COMPLETE FINANCIAL CONSENT FORM

  • Submit Your Forms

    Please complete both required forms online and submit each form electronically by clicking the SUBMIT button at the end of the form.
    Both the General Consent to Treat Form and Financial Consent Form must be completed and electronically submitted as part of your patient intake before your appointment is confirmed.

    Privacy Notice

    All patient information is kept confidential and is securely stored according to HIPAA guidelines. By submitting this form, you consent to the use of your data for medical purposes only.
    Please click the button below to review our HIPAA Privacy Policy.
HIPAA PRIVACY POLICY

Patient Information Form

Please provide the following information to help us serve you.
Full Name Date of Birth Address Phone E-mail Emergency Contact Name Enter Emergency Contact Phone Preferred Pharmacy Insurance Provider Insurance Member ID Patient Signature & Date | By signing below, you confirm that the information provided is accurate and agree to the terms outlined in our Patient Policies. HIPAA Privacy Acknowledgment I acknowledge that I have received the Notice of Privacy Practices from Call Doctor Packer Telemedicine. Consent for Treatment I consent to medical evaluation and treatment by Call Doctor Packer Telemedicine. I understand medical care may include diagnostic testing and treatment. Financial Policy & Billing Agreement I agree to be financially responsible for all services provided. I understand copays and deductibles are due at time of service. Authorization for Release of Medical Records I authorize Call Doctor Packer Telemedicine to obtain or release my medical records. Insurance Assignment of Benefits I authorize payment of medical benefits directly to Call Doctor Packer Telemedicine. Electronic Communication Consent I consent to receive appointment reminders and communications via email, phone, or text message. Telemedicine Consent I consent to receive medical services via telemedicine. I understand telemedicine has limitations and may not replace in‑person evaluation when necessary. No‑Show / Late Cancellation Policy I understand appointments cancelled with less than 24 hours notice or missed appointments may incur a fee. Authorization to Charge Card on File I authorize Call Doctor Packer Telemedicine to charge my card for copays, balances, or missed appointment fees. Photo ID and Insurance Card Submission. Please attach or upload a copy of your government ID and insurance card. Primary Medical Conditions Current Medications Allergies Past Surgeries/Hospitalizations Family Medical History
SMS opt in
I agree to receive SMS/text messages from Call Doctor Packer Telemedicine regarding services, scheduling, and account updates. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for assistance. Consent is not a condition of purchase.
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