Secure patient form

Telehealth consent

Some visits may be by video or phone, depending on your state and whether you're a new or returning patient. Please read and agree to each statement before a telehealth visit with Dr. Ewals. You can ask for an in-person visit in Grand Forks instead.

Required

Patient

First name

Last name

Date of birth

Phone

Where will you be during the visit?

Telehealth is only possible while you're in North Dakota or Minnesota, as your state allows.

North Dakota Minnesota

Telehealth

Signature

Typing your full legal name here is your electronic signature.

Today's date

If you are signing for the patient, your relationship to them

For example, parent, legal guardian or personal representative.

Sent privately to our care team