eVisit consent


Informed Consent for Telemedicine Services Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

  • Patient medical records

  • Medical images

  • Live two-way audio and video

  • Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.Expected Benefits:

  • Improved access to medical care by enabling a patient to initiate a visit and consult a healthcare practitioner at a distant/other sites.

  • Medical images

  • More efficient medical evaluation and management.

  • Obtaining expertise of a distant specialist.

Possible Risks:


As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

  • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);

  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;

  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;

  • In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;

By agreeing to this form, I understand the following:

  1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my consent.

  2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

  3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.

  4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.

  5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

  6. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.

  7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

  8. I understand that I am not allowed to record any or all parts of the e-visit encounter with the healthcare provider

  9. I understand that some medical conditions may require physical exam, therefore not every medical condition could be fully addressed by an electronic visit.

  10. I understand controlled medication will not be prescribed during an e-visits, they can only be prescribed during an office visit in person.

  11. I understand that e-visits are cash pay visits and are not filed to insurance. My credit card will be charged based on the time spent in the visit ( Nonrefundable ) .

    • -New patient consultation up to 30 minutes $200.00

    • -Established patient visit of 15 to 30 minutes $150.00

    • -Established patient visit of up to 14 minutes $75.00

    • Nutrition appointments ONLY; Platinum and Gold members: fees are included in the monthly plan charge.      

      • -30 minutes $30.00 -60 minutes $45.00


Patient Consent to the Use of Telemedicine I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.


Complete the form below to acknowledge consent for participation in the eVisit program. We look forward to serving you with all of your medical needs in a manner that offers you convenience. If you need immediate assistance, please contact us at (850) 522.5490.









I hereby give my permission for the Institute of Endocrinology, Diabetes, Health and Hormones (IEDHH) to use my information for the purposes of communicating medical information via the eVisit program effective on the date of submission of this form. I understand that the staff of IEDHH will have access to my medical information.





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The Institute of Endocrinology

Diabetes | Health | Hormones | Weight Loss | Medical Spa


Panama City Office

633 E Baldwin Rd, Panama City, FL

   (850) 522.5490

The Medical Spa in town on Baldwin Road has relocated to the Beach Office. If a patient wants to get injectables they can see Dr. Kamel at either the Baldwin, Beach or Destin Office. Please call 850-867-0860 to setup injectables (Botox and Juvederm) appointments.








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