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Agreement for Patient

Last updated January 22, 2024

Consent Form for Teleconsultation

  1. Purpose: To obtain your consent to participate in a teleconsultation in connection with the following service(s) and/or procedure(s)
    1. Patient Health Records
    2. Medical Images
    3. Live audio and video interaction
    4. Output data from medical devices and sound and video files
  2. Electronic systems: Electronic systems used will incorporate network and software security protocols to protect confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional and unintentional corruption in accordance with applicable Laws and Regulations.
  3. Nature of Teleconsultation: During the teleconsultation
    1. Details of your medical history, examinations, x-rays and tests may be discussed with other healthcare professionals with interactive videos, audio and telecommunication technology.
    2. A physical examination may need to take place.and doctor or medical technical person could ask you to show some of your body parts for examinations.
    3. A medical technical person may be present in the telehealth clinic to aid the docotr.
    4. Audio and/or photo recordings may be taken for accurate diagnosis, treatment and quality control.and the doctor or the medical technical person will ask you before he do this for your consent and agreement.
  4. Medical Information and Records: All existing laws and local regulations/policies/guidelines regarding access to medical information and copies of your Health Records apply to this teleconsultation. Dissemination of any patient identifiable images or information for this telehealth interaction to other entities will not take place without your consent.
  5. Confidentiality: Responsible and appropriate efforts have been made to eliminate any confidentiality risks associated with the teleconsultation and all existing confidentiality protections under applicablelaws and local regulation apply to information disclosed during this teleconsultation.
  6. Rights: You may withhold or withdraw consent to teleconsultation at any time without affecting your right to future care or treatment.
  7. Disputes: You agree that any disputes that arise from the teleconsultation will be resolved as per laws and regulations of the country where remote health service provider is licensed to provide such health services and will be raised with the telehealth provider in the first instance.
  8. Expected Benefits:
    1. Audio and/or photo recordings may be taken for accurate diagnosis, treatmImproves access to medical care by enabling a patient to remain in their home, office (or a remote site) while your licensed physician obtains test results and consults with other licensed physicians at distant/ other sites.nt and quality control.and the doctor or the medical technical person will ask you before he do this for your consent and agreement .
    2. More efficient medical evaluation and management.
    3. Access to expertise from distant specialist in your country or experts outside.
  9. Possible Risks: As with any medical procedures there are potential risks associated with the use of Telehealth, which may include, but not limited to the following:
    1. Information transmission may not be sufficient (e.g. poor resolution of images) to allow appropriate decision making by the consulted physician.
    2. Delays in medical evaluation and treatment could occur due to deficiencies or failure of equipment.
    3. In rare instances, security protocol could fail causing a breach of privacy of personal medical information.
    4. In rare cases, a lack of access to complete health records may result in adverse drug interactions, allergic
  10. Expected Benefits and Possible Risks: You have been advised of all the risks, consequences and benefits of telehealth. Your treating physician has discussed with you the information provided in a language you can understand. You have had the opportunity to ask questions about the information presented in this form and about the teleconsultation. All your questions have been answered and you understand the written information provided above. when you click the link of start call that mean you are agree all terms and condition and you are consent all above.

I agree to participate in the teleconsultation for the service(s)/procedure(s) mentioned above.