Patient Forms · Telehealth

Consent to Telehealth Visits

Read and sign this before your first video visit — about 3 minutes.

Send it online when you finish, or print it and bring it to your visit. What you send goes securely to our office’s patient system. Nothing is sent until you press Send, and nothing you type is saved on this device.

Urological Consultants of Florida
12411 Biscayne Boulevard, North Miami, FL 33181 · (305) 672-4222 · www.miamiurologyconsultants.com

Consent to Telehealth VisitsTELE-1 ยท v2026.11.0

Consent to Telehealth Visits

About 3 minutes · TELE-1 · v2026.11.0

All fields are required unless marked (optional).

About you

MM/DD/YYYY

About telehealth
Signature
Who is signing?

For example: parent of a minor; court-appointed guardian; health care surrogate; power of attorney. Please bring a copy of the document that gives you authority.

Signature of patient or personal representative

Review and send

When you have finished, send your answers to our office. Nothing is sent until you press Send to the practice. You can also print your form and bring it instead.

Sent securely to our office’s patient system. This page does not save what you type on this device.

What to bring to your visit

  • Photo ID
  • Your insurance card(s)
  • Your medication list or bottles
  • Any referral or recent records, if you have them

Questions? Call (305) 672-4222, Monday–Friday, 9:00 am – 5:00 pm.