I have read and understand the above information regarding the service I am seeking, and all my questions have been answered. I hereby give informed consent to use Telehealth and/or Telemental Health and/or Teledental services in my care or care of my dependent. This form is valid for one year from date of signature and must be updated annually or if any information changes.
We have 30+ locations to better serve you in your town.
Copyright by ValleyHealth.org