Informed Consent to avail Telemedicine Consultation

I have chosen to consult with the healthcare provider of my choice through tele-consultation on my own accord and I understand the following:

1. The purpose of the tele-consult is to assess and treat my medical condition.
2. The telemedicine consult is done through a two-way video link-up whereby the physician or other health provider can see my image on the screen and hear my voice. However, unlike a traditional medical consult, the physician or other health provider does not have the use of the other senses such as touch or smell; and it may not be equal to a face-to-face visit.
3. Since the telemedicine consultants practice in a different location and do not have the opportunity to meet with me face-to-face, they must rely on information provided by me or my onsite healthcare providers. The healthcare provider or the platform can not be responsible for advice, recommendations and/or decisions based on incomplete or inaccurate information provided by me or others.
4. I can ask questions and seek clarification of the procedures and telemedicine technology.
5. I can ask that the telemedicine exam and/or videoconference be stopped at any time.
6. I know there are potential risks with the use of this technology. These include but are not limited to:
1. Interruption of the audio/video link.
2. Disconnection of the audio/video link
3. A picture that is not clear enough to meet the needs of the consultation.
4. Electronic tampering. If any of these risks occur, the procedure might need to be stopped.
7. I am willing to pay the consultation fees and any platform fees and financial charges mentioned if any for the tele-consultation.

I certify that I have read the above and I understand and agree to its contents and hereby give my informed consent to avail medical consultation via telemedicine.