TeleTots Pediatric Urgent Care
Virtual Waiting Room
Skin Eczema in Children – A Complete Guide
Eczema or atopic dermatitis (as it is medically called) is a condition that approximately 10% of children suffer from. Skin eczema in children is a...
Food Allergies in Children: Everything you should know
What are food allergies in children? A food allergy is an abnormal reaction of the body to a certain food. The reaction usually happens shortly...
5 Tips To Prevent Summer Injuries For Kids
Summer indicates a lot of kids are going to play outside. Like always, it's crucial to keep children healthy and prevent them from summer injuries....
5 Common Causes of Cough in Children
From allergies to aspiration and colds, there are many causes of cough in children. Hearing your kids cough for hours can be bothersome. However a...
Tips to Prevent Sinus Infections
Its common knowledge that colds and runny noses increase during the winter and allergy season. However, this can be even worse when your cold becomes...
How to Protect Your Kids from Colds, Flu and other viruses like Coronavirus
From taking care of their hygiene to giving them some right food to eat, here are some ways to protect your kids from common viruses...
Why should you consider Telemedicine for your Children
From the instant care provided to reduced time and cost, here are some of the top benefits of telemedicine for your kids. It is quite...
Tips To Treat Sinus Infections
These easy ideas can help you relieve sinus infections at home. Also known as sinusitis, a sinus infection is a condition marked by the inflamed...
What to Consider Before Choosing a Pediatric Urgent Care Clinic
The popularity of pediatric urgent care clinic largely rests on the unpredictable illness and injury risks among the kids. Besides, they are less expensive than...
How Telemedicine Helps Your Kids with Cold and Flu
The arrival of the fall season in the USA also marks the beginning of flu and cold. Kids are more prone to these health conditions, not just...
Virtual Waiting Room
Fill the form to enter Virtual Waiting Room
Patient Last Name
Patient First Name
Date of Birth
Reason for visit
Colds, Respiratory illnesses
Mild asthma exacerbation
Vomiting, Diarrhea & constipation
Past Medical History
Any recent ER or urgent care visit
(if yes was it for )
Pharmacy phone number
Parent/Guardian First Name
Parent/Guardian Last Name
Consent to treat
Consent to use Telemedicine
Consent to Treat
I understand that my health care provider wishes me to engage in a telemedicine consultation.
My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.
In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference connection.
I understand that billing will occur from both my practitioner and as a facility fee from the site from which I am presented.
I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
By signing this form, I certify:
That I have read or had this form read and/or had this form explained to me
That I fully understand its contents including the risks and benefits of the procedure(s).
Date & Time
Virtual Waiting Room