|
Visit Type
|
|
|
Telehealth
|
Telehealth Platform:
|
|
Consent given by:
|
|
|
Patient's location
|
Provider's Location
|
|
Interpreter service used
|
Interpreter services used
|
|
History of Present Illness
|
|
|
Seen by request of
• • •
|
Information from
• • •
|
|
Medical Necessity
• • •
|
|
|
Condition 1
|
Condition 2
|
|
Condition 3
|
Condition 4
|
