Telehealth is a video chat that works just like the popular iPhone FaceTime or Google Duo apps, so patients can make an appointment in the privacy of their own home and speak face to face with one of our physicians. You can view the telehealth instructions by clicking here. Please note that instead of following step 2 in the instructions, we will text or email you the link to make it easier!

For Our Current Patients:

Due to COVID-19, we are trying to see as many of our current patients as we can via telehealth.
Please read and sign the form below. Thank you!

If You Are Completing Your Application to Become a Patient:

This is the last step in completing your application. Please read and sign the form below. Thank you!

If You Are Not a Current Patient:

Please begin our Patient Eligibility process by clicking here.

  • TELEHEALTH INFORMED CONSENT FORM

  • I, being physically located in Virginia, hereby consent to engaging in telehealth with Lackey Clinic as part of my medical treatment. I understand “telehealth” means the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand telehealth involves the communication of my medical information both orally and visually to a health care provider at Lackey Clinic located in Virginia.
  • I understand I have the following rights with respect to telehealth:
  • (1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
  • (2) The laws that protect the confidentiality of my medical information also apply to telehealth. I understand the audiovisual information transmitted electronically will be encrypted during transmit and will not be stored. I also understand the dissemination of any personally identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without my consent. I understand the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
  • (3) I understand there are benefits, risks and alternatives involved with telehealth. Benefits include having access to medical care without having to travel outside of my local community. A potential risk of telehealth is because of my specific medical conditions, or due to technical problems, a face-to-face consultation still may be necessary after the telehealth appointment. Despite reasonable efforts on the part of my physician, the transmission of my medical information could be disrupted or distorted by technical failures. In rare circumstances, security protocols could fail causing a breach of patient privacy.
  • (4) I understand telehealth based services and care may not be as complete as face-to-face services. I also understand if my physician believes I would be better served by another form of services (for example face-to-face services) I will be referred to a physician who can provide such services in my area.
  • (5) I understand I may benefit from telehealth, but the results cannot be guaranteed or assured.
  • (6) I understand I have a right to access my medical information and copies of my medical records in accordance with Virginia law.
  • Type full name to sign.
  • Date Format: MM slash DD slash YYYY