TeleTots Pediatric Urgent Care
Virtual Waiting Room
How to Choose the Right Telehealth Solution
Over the last few years, telehealth has seen immense growth and popularity. Almost 76% of US hospitals today have virtual care to offer so that...
How to Prepare Kids for Telehealth Appointments
Over the years, there has been a boom in telehealth visits. These virtual appointments let healthcare professionals deliver care to the patients at the comfort...
Telehealth Trends in 2020 and Beyond: What to Know
Telehealth Trends in 2020: Telehealth has become more relevant in 2020. The coronavirus outbreak has discouraged most people from visiting the clinics, making them opt...
Questions to Ask Before Choosing a Telemedicine Provider for Children
Here you'll get to know some questions to consider while choosing a telemedicine provider. But first, lets start with the basics. Telemedicine is the practice...
What Are The Benefits of Virtual Pediatric Care?
Ever wondered about the benefits of virtual pediatric care? Picture this— Your kid experiences endless bouts of cough in the middle of the night during...
What Is the Advantage of Telehealth for Patients?
What is the advantage of telehealth? The outbreak of COVID 19 has cast an uncertain time over the world. It has made social distancing downright...
Telehealth During COVID-19 Pandemic
What is the role of telehealth during Covid-19 pandemic? With the pandemic around for some months now and looking to continue yet, the need arose...
What is the Difference between Telehealth and Telemedicine?
The terms telehealth and telemedicine are often used interchangeably. Or you can say that these terms are confused with each other. Popular to the contrary...
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...
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