I confirm I am 13 years of age or older. If under 18 years of age, I confirm that my parent or legal guardian is completing this form, consents to care, and will be present during the telehealth visit.*

I have read and agree to the Desert Agave Wellness Telehealth Informed Consent document.*

I confirm that I will be physically located in Arizona, Colorado, Nevada, or New Mexico during my telehealth visit.*