Purpose: The Purpose of this form is to obtain your consent to participate in a telemedicine consultation in connection with the following procedure(s) and/ or service(s)
Nature of Telemedicine Consult: During the telemedicine consultation:
a. Details of your medical history like chief complaint, history of present illness, review of systems, past medical history, family history, immunization, examinations, laboratories and ancillaries results, etc. will be discussed with other health professional through the use of interactive video, audio and telecommunication technology as part of the therapy process and my treatment goals.
b. A limited physical examination of you may take place.
c. A non-medical technician may be present in the telemedicine studio to aid in the video transmission and will maintain confidentiality of the information obtained.
d. Video, audio and/or photorecordings may be taken of you during the procedure(s) or service(s)
e. May include mental health evaluation, assessment, consultation, treatment planning and therapy.
f. Certain situations including emergencies and crises are inappropriate for telemedicine services. In case of emergency or crisis, patient should go to the nearest hospital.
Medical Information & Records: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent.
Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with telemedicine consultation, and all existing confidentiality protection under the Philippine Law apply to information disclosed during telemedicine consultation. The information released by me or patient during the course of my session is confidential, just as it would be if I were in the clinic. The visit is transmitted over dedicated lines and cannot be accessed by any unauthorized individuals.
Rights: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting you right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise entitled.
Disputes: You agree that any dispute arriving from telemedicine consult will be resolved in Batangas City, and that Philippine law shall apply to all disputes
Risks, Consequences and Benefits: You have been advised of all the potential risks, consequences and benefits of telemedicine. Your healthcare practitioner has discussed with you the information above. You have the opportunity to ask questions about the information presented in this form and the telemedicine consultation. All your questions have been answered,and you understand the written information provided above.
(If you agree with the statements above, please tick the boxes)