Your child’s health and safety are our top priority at Medivive. This form ensures we have your consent as a parent or legal guardian to provide telehealth services for your child. We’re here to make this journey comfortable, secure, and centered on your child’s well-being.
As a parent or legal guardian, your involvement is essential in your child’s care. By providing consent, you agree that:
We ensure you are fully informed and involved in your child’s care. By signing below, you acknowledge that:
If your child’s provider prescribes medication, we will ensure you fully understand the prescription and its usage. You can always reach out if you have any questions or concerns about your child’s medication.
Parent/Guardian Signature: __________________________________________
Date: _____________________
If lab work is required, we will help you schedule it at a facility close to your home. We will keep you informed of the results and how they impact your child’s care plan.
Parent/Guardian Signature: __________________________________________
Date: _____________________
As the parent or legal guardian, I give consent for Medivive to provide telehealth services to my child.
Parent/Guardian Name (Printed): __________________________________________
Relationship to Patient: __________________________________________
Parent/Guardian Signature: __________________________________________
Date: _____________________
Please select the services that apply to your child’s healthcare needs:
Please check the services you’re interested in for your child:
While your child’s health is our priority, please contact 911 or visit the nearest emergency room in case of an emergency. For non-emergencies, you can reach out to your provider through our patient portal.
Parent/Guardian Signature: __________________________________________
Date: _____________________
At Medivive, we are dedicated to ensuring your child’s well-being, every step of the way. We value the trust you place in us as we work together to keep your child healthy and happy.
“Our telehealth services are designed to provide convenient, remote healthcare, but certain conditions may require in-person care. Our providers will refer you to a trusted local provider if your needs extend beyond telehealth.”
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