I hereby authorize Daryl Ann Smith to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing any medical condition.

I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.

I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.

I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

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