(812) 723-3944  


School Telehealth Consent Form_OC

MM slash DD slash YYYY
School the Patient Attends (if a Student)(Required)
Patient's Grade (if a student)(Required)

Verbal Consent for Each Visit

In addition to written consent, for any patient under the age of 18, a parent/guardian will be contacted before each visit to receive verbal consent. If the verbal consent cannot be provided due to inability to answer phone, phone number disconnected, etc. please indicate if the patient can or cannot be seen by a provider at the Telehealth Clinic. Please initial the appropriate line below regarding verbal consent.

Permission to be seen(Required)
Choose only one option

Sharing Records with Primary Care Provider (PCP)

Telehealth Clinic providers will provide a copy of the visit's medical record, including lab results, medications prescribed, assessment and plan of treatment for any patient that has an established primary care provider outside SICHC. Sharing of medical information with the PCP requires the consent of the patient or patient’s parent/guardian.

Sharing records with Primary Care Provider (PCP)(Required)
Choose only one option

Primary Care Physician Consent - Contact Information

If you consented to share medical information with the patient's PCP (from above), please provide their contact information:

Primary Care Physician Consent - Contact Information
Physicians Name


Southern Indiana Community Health Care, Inc. may order in-house laboratory tests (strep, flu, etc.) to determine the appropriate diagnosis and treatment plan. Please initial if the provider can order in-house labs for the patient.



As the patient or parent/guardian of the patient, I:

Please check all statements you agree to


I have had the opportunity to read this form in its entirety and understand the information provided. All my questions have been answered to my satisfaction. The information on the proceeding pages is true and complete to the best of my knowledge.

My name typed into the answer space to this statement serves as my electronic signature.
MM slash DD slash YYYY



MM slash DD slash YYYY

© 2023 Southern Indiana Community Health Care.   PRIVACY

Social Media