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Telemedicine Consultation Form
Terms and Conditions
Introduction and Purpose:
Telemedicine is the use of a telephone, cellphone, computer or electronic gadget that will enable me as a patient to communicate with my doctor/s for the purpose of diagnosis, treatment, management, education and follow-up care when a face-to-face consultation is not possible. Telemedicine consultations may involve live two-way audio and video, patient pictures, medical images, patient’s medical records and other things that may be pertinent to the consultation.
Electronic systems will utilize network and software security protocols to protect patient identity, privacy and confidentiality and to safeguard data and prevent corruption of data against intentional or unintentional corruption.
By participating in this teleconsultation, I acknowledge that a physician-patient relationship is formed at my request.
Nature of the telemedicine consultation:
It was explained to me by my doctor that a video conferencing technology will be used to conduct a telemedicine consultation. I understand that as in the face-to-face consultation, I will be asked to give my history, share my laboratory test and imaging results and other documents pertinent to my concerns. Moreover, I may be asked to show certain body parts as may be considered important to form a diagnosis. This is in view of the fact that my doctor will not be in the same room as I am and would not be able to perform the necessary physical examination on me.
Through the use of telemedicine, I will obtain a medical evaluation and impression of my condition. I may receive guidance on monitoring my condition and the next steps to do should my condition change, specific prescription on what to take, instructions on what laboratory and imaging tests to do.
I understand there are potential risks in using this technology, including technical difficulties, interruptions, poor transmission of images leading to misdiagnosis and consequently mistreatment, no access to paper charts/medical records, delays and deficiencies due to malfunction of electronic equipment and software, unauthorized access leading to breach of data privacy and confidentiality.
All consultations are considered confidential but given the nature of technology, I understand that despite using appropriate measures, my doctor cannot guarantee the safety of my personal data from data hacking. Therefore, I cannot hold my doctor liable for any data that may be lost, corrupted, destroyed or intercepted or the illegal use of my data arising from a breach in security.
Data Privacy and Confidentiality:
I agree to share my personal data with the clinic or hospital staff of my doctor in order to facilitate scheduling of my consultation and for billing purposes. I agree not to record in video or audio format nor divulge the details of my consultation in compliance with the Data Privacy Act of 2012.
I have the right to:
1. Ask non-medical staff to leave the telemedicine consultation room.
2. Terminate the telemedicine consultation and the physician-patient relationship at any time.
3. Obtain a copy of the information obtained and recorded during the telemedicine consultation.
4. Be assisted by a family member or caregiver in the set-up of the telemedicine at home and to answer some questions.
The clarity of the images, audibility of the sound, the speed of the internet, the presence of background noise all affect the quality of the telemedicine consultation. Physical examination as done in the usual face-to-face consultation is not possible and is therefore a big limitation to the process of making a diagnosis.
In case of an urgent concern:
It is my doctor’s responsibility to refer me to the nearest hospital in case he deems my concern to be urgent and would warrant immediate action and management by doctors. My doctor’s responsibility ends with the conclusion of the telemedicine consultation.
By signing this consent form, I hereby declare that I have read this form and that I fully understand what is stated here. I was given the opportunity to ask questions and my questions were answered.I have discussed these with my doctor and I fully understand the risks and benefits of telemedicine consultation as they were shared in a language that I can understand.
Viber - please indicate phone number
FB Messenger - please indicate name
Zoom - password will be provided upon payment