Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred method of contact *

Text

Phone Call

Email

Communication Consent *

I understand that standard email, phone, and text messages are not guaranteed to be secure and may expose personal health information. I authorize Telehealth of USA to communicate with me via phone, email, or text for non-urgent matters, appointment reminders, or follow-up questions, knowing that there is some risk to my privacy.

I agree to be contacted