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Informed Consent for Telemedicine Services
Patient First Name
Patient Last Name
Birthday
Email
Phone
Choose Your Provider(s)
Judey Budenz-Anders, PhD, HSPP
Julie Harrell, LCSW
Connie Leese, CNS-BC
Sara Miller, NP
Paige Pine, LCSW
Jayne Ribble, LMHC
Angela Roegner, LCSW
Ronald Williams, LCSW
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