Telemedicine Informed Consent Form

What is Telemedicine?

Telemedicine is a method of conducting the practice of medicine by a doctor with a patient through remote means such as a computer with the use of the internet that has the capability for audio and video communication. With this method, the patient need not go to the place of the physician or the latter need not go to where the patient is.

Purpose

The purpose of this form is to obtain your consent to participate in a telemedicine consultation without the need to travel in connection to consultation services needed by the patient.

Risks

Since the transmission of information relies on electronic methods such as the internet, transmission of information may be intermittent or may yield poor results in rare cases, or inaccessibility to records. As such, there can be tendencies of delay in the evaluation, diagnosis, and/or treatment.

There is likewise no perfect security. Breaches may occur but rest assured, we are always doing our best to ensure up to date security measures are in place all the time.

 Nature

During consultation details of your medical history, medical exams, scans, and x-rays will be discussed with you by a physician or any other health professional and by which medical examinations may take place. A technician may be present to ensure seamless video and audio communication and transmission between the physician and the patient. This video and audio communication may be recorded for documentation purposes. 

Benefits

With telemedicine, there is more efficiency in terms of time usage and management. No need to travel to the clinic and get the services you need. You can be anywhere, even in your own home.

Medical Records

All laws currently in force relating to access and use of medical records shall apply to this telemedicine informed consent. Use and access to all patient information shall strictly be followed and will require the patient's consent. However, please be informed that any use for statistical data and research will not need the consent of the patient, so long as he or she is not identified.

Confidentiality

We believe in respect to the privacy and confidentiality of each and every individual. Thus, we apply reasonable and appropriate security measures and procedures to eliminate any possible security breaches that may arise in relation to this telemedicine consultation. 

Billing

Billing shall be made coming from the facility of the telehealth service provider as well as from the physician. This may either be separate or coming from one billing statement.

Your Rights

Given that your consent to this telemedicine consultation is voluntary, you have your right to withhold or withdraw your consent at any time. By your withholding or withdrawal, your relationship with us will not be affected with regard to your future treatment and/or consultation with us in the future. You are still entitled to other benefits that do not need your consent.

By signing this form, I hereby declare that I agree in participating in the telemedicine consultation. I have had the opportunity to ask questions and by which were answered to me to my satisfaction. I voluntarily give my consent and not in any way that my consent was vitiated nor was I coerced.