Name *

First Name

Last Name

Phone

(###)

###

####

Telehealth Consent Acknowledgment *

By submitting this form, I acknowledge that I am requesting a telehealth consultation with Remedy Skin, Hair, and Wellness. I understand that telehealth involves the electronic communication of my medical information for assessment, diagnosis, and treatment planning. I further understand that I will receive a detailed Telehealth Consent Form to review and sign before my consultation is confirmed.

I acknowledge and agree to proceed with the telehealth consultation request.

Restrictions on location

I am currently located in NC at the time this consultation is being conducted