New Patient Registration | KidsDocTelehealth

👶 Child's Information

Please enter your child's details exactly as they appear on their insurance card or birth certificate.

First Name *

Last Name *

Date of Birth *

Sex Assigned at Birth *

Preferred Pronouns (Optional)

👨‍👩‍👧 Parent/Guardian Information

This is the primary contact who will receive all communications and be present during visits.

Parent/Guardian First Name *

Parent/Guardian Last Name *

Relationship to Child *

Preferred Language *

Email Address *

Mobile Phone *

Home Address *

City *

State *

ZIP Code *

🚨 Emergency Contact

Someone we can contact if we cannot reach you. Must be different from primary parent/guardian.

Emergency Contact Name *

Relationship to Child *

Emergency Contact Phone *

💊 Pharmacy Information

Where should we send prescriptions?

Pharmacy Name *

Pharmacy Phone *

Pharmacy Address *

💡 Tip You can find your pharmacy's phone number on any prescription bottle or by searching online.

📜 Practice Policies & Disclosures

Please review the following policies carefully. You will be asked to acknowledge them at the end.

💳 Payment Policy

Single Visit: $75 for a 15-minute acute illness visit
Monthly Membership: $145 for extended/complex visits (25 min)
Sibling Discount: $225 for guidance visits (30 min)
Payment is due at the time of service via credit card, debit card, or bank transfer
We do not bill insurance directly. You may submit receipts to your insurance for possible reimbursement
No refunds for completed visits

📅 Appointment & Cancellation Policy

Please arrive to your video visit on time
If you need to cancel or reschedule, please do so at least 2 hours before your appointment
No-shows or late cancellations may be charged a $25 fee
If you are more than 10 minutes late, your appointment may need to be rescheduled

💬 Communication Policy

Routine questions and follow-ups can be sent via secure messaging
We aim to respond to messages within 24 hours on business days
Urgent concerns require a telehealth visit
We are NOT available for emergencies — call 911 or go to the ER
After-hours messages will be answered the next business day

💊 Prescription Policy

Prescriptions are sent electronically to your chosen pharmacy
Refill requests require a telehealth visit if the child hasn't been seen in the past 3 months
We do not prescribe controlled substances at this time (including ADHD stimulants, narcotic pain medications, anti-anxiety medications)
Certain medications require an in-person visit and cannot be prescribed via telehealth

📂 Medical Records Policy

Your child's medical records are maintained securely in compliance with HIPAA
You may request copies of records at any time
With your consent, we can share records with your child's primary care provider or specialists
We retain records for 7 years after the last visit (or until the child turns 21, whichever is longer)

🩺 Scope of Services

KidsDocTelehealth provides pediatric care for children ages 0-21 including:

Sick visits (fever, cough, cold, flu, ear pain, pink eye, rashes, etc.)
Allergies and skin conditions
Asthma management
Prescription refills and medication management
School and camp forms
Follow-up care
Parenting guidance and counseling
Breastfeeding support
Developmental concerns
Mental health support (non-emergent)

Not included: Well-child visits requiring physical examination, vaccinations, in-person procedures, emergencies, or conditions requiring in-person evaluation.

📍 Service Area

Dr. Hussain is licensed to provide telehealth services in the following states. Your child must be physically located in one of these states at the time of the visit:

Maryland and Washington DC

⚠️ Emergency Disclaimer

KidsDocTelehealth is NOT for emergencies.

If your child is experiencing any of the following, call 911 or go to the nearest Emergency Room immediately:

Difficulty breathing or severe shortness of breath
Choking
Severe allergic reaction (anaphylaxis)
Unresponsiveness or difficulty waking
Seizures
Severe bleeding
Signs of meningitis (stiff neck, high fever, altered mental status)
Suicidal thoughts or self-harm
Any condition you believe is life-threatening

✓ Policy Acknowledgment By proceeding to the next step, you confirm that you have read and understand these practice policies.

✍️ Telehealth Informed Consent

Please read each section carefully and check the boxes to indicate your understanding and agreement.

📱 What is Telehealth?

Telehealth allows you to receive healthcare services remotely using technology such as video conferencing. Instead of visiting a medical office, you connect with your healthcare provider from your home or another private location using a computer, tablet, or smartphone.

✅ Benefits of Telehealth

Convenient access to pediatric care from home
Reduced travel time and expenses
Decreased exposure to illnesses in waiting rooms
Flexible scheduling
Access to board-certified pediatric expertise

⚠️ Limitations of Telehealth

Physical examination is limited to what can be observed via video
Some conditions require in-person evaluation and cannot be diagnosed via telehealth
Technical difficulties may interrupt or prevent the visit
Certain tests, procedures, and vaccinations cannot be performed remotely
The provider may determine that telehealth is not appropriate and recommend in-person care

🔒 Privacy & Security

We use HIPAA-compliant telehealth technology to protect your privacy. Your medical information is kept confidential according to state and federal law. However, electronic communications carry some risk of unauthorized access despite security measures. Please:

Use a private, quiet location for your visit
Use a secure internet connection (avoid public WiFi)
Do not record the telehealth session without consent

Consent Acknowledgments

About Your Provider

Maria Hussain, MD is a board-certified pediatrician with over 20 years of medical experience, including pediatric emergency and NICU care. She is licensed in Maryland and Washington DC.

✅ Review & Submit

Please review the information below before submitting. Click "Edit" to make changes.

Child's Information Edit

Name

—

Date of Birth

—

Sex

—

Parent/Guardian Information Edit

Name

—

Relationship

—

Phone

—

Address

—

Medical Information Edit

Allergies

—

Current Medications

—

Vaccination Status

—

Pharmacy

—

Consents Provided

✓ Telehealth Informed Consent
✓ Payment Policy Agreement
✓ Practice Policies Acknowledgment
✓ Emergency Care Understanding
✓ Consent to share records with PCP

Electronic Signature

By typing your name below and submitting this form, you are signing this document electronically. You agree that your electronic signature has the same legal effect as a handwritten signature.

Type Your Full Legal Name *

Today's Date

I confirm that all information provided is accurate to the best of my knowledge, and I agree to the terms and conditions, privacy policy, and telehealth consent as described above.

✓

Registration Complete!

Thank you for registering with KidsDocTelehealth. We've received your information and you're all set to book your first visit.

What's Next?

Check Your Email

You'll receive a confirmation email with a copy of your registration.

Book Your First Visit

Schedule a telehealth appointment at your convenience.

Prepare for Your Visit

Find a quiet, private space with good internet connection.

Return to Homepage Book a Visit