Consent for TelePsychiatry & Consent for treatment with medication

At Mid-Florida Psychiatry Center, a TelePsychiatry virtual clinic, Dr Vangala has Physician Associates and Psychiatric Nurse Practitioners (AHP’s)who work along with Dr Vangala in seeing patients for medication management, either during initial visit or follow up visits. If an AHP has done assessment and unable to review with MD or the team are unable to come to conclusion of diagnosis and treatment plan, you may asked to schedule a follow up appointment prior to prescribing medication.

Also, Dr Vangala is teaching Medical students, PA students and Nurse practitioner students in this clinic. You may come across these students, who are just gathering the information and learning from either Dr Vangala or his AHPs. Please notify the staff if any specific requests.

By completing this paperwork, it’s implied that you are aware of/ read the clinic setting (tele visits) /POLICY and are consenting to be treated in this clinic.

By completing this paperwork, its implied that you are aware of/ read the risks, benefits and alternatives to treatment with medication as mentioned in the ATTACHED SHEET. Also you will provide a verbal consent to treatment with individual, specific medication and doses, at the time you meet with the providers. You will also contact us if any unexpected side effects immediately.

First Name

Last Name

Date of Birth

Consent for TelePsychiatry

I have read the above terms and conditions of the TelePsychiatry policy of Mid-Florida Psychiatry Center, and I do cnsent to be treated

I agree to the terms & conditions, reviewed the policy on medication use, and consent to be treated with medication.

Thanks for sending the consent form

Vidyasagar Vangala, MD; FAPA

Consent for TelePsychiatry & Consent for treatment with medication

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