TELEHEALTH SERVICES AUTHORIZATION AND CONSENT FORM

Patient First Name

Patient Last Name

Provider: Healing Thyme Concierge Nursing LLC, 90 Far Horizon Dr. Cheshire, CT 06510

Phone: 203-295-4265

Jill Connolly, MSN, RN, License #82428

Consent to Telehealth: I consent to receive telehealth services (audio/video consults via [Zoom/Doxy.me/etc.]) for concierge nursing, post-procedure follow-up, referral coordination, and wellness support. Services will meet in-person standards using peripheral devices if needed.

Risks & Limitations Understood:

Possible technical issues (e.g., connection drops, audio-only fallback).
Not a substitute for emergency care—call 911 if needed.
Privacy risks (e.g., secure my end: private room, no recording).
Location: I am physically in Connecticut during visits.

Provider Info: You provided your license number, contact details, and access to my medical history/PCP (if any). Records may be shared with my PCP if I consent below.

Expiration/Revocation: Valid for:

1 year

Ongoing until revoked. I may revoke anytime in writing; revocation documented in my record (doesn't apply retroactively).

PCP Disclosure:

Do NOT share telehealth records with my PCP

Yes, share telehealth records with my PCP: Name/Address:

Name/Address of PCP:

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