Telehealth Interaction Facial Consent Form
Please review and complete this consent form to authorize facial image or video capture during your telehealth session.
Full Name
*
First Name
Last Name
Email Address
example@example.com
Date of Telehealth Session
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please confirm your role in this telehealth session.
*
Patient
Participant (not the patient)
Parent or Legal Guardian
Consent Declaration
*
Do you understand and agree to the above consent declaration?
*
Yes, I understand and agree.
No, I do not agree.
Signature
*
Submit Consent
Submit Consent
Should be Empty: