Consent for Telemedicine/Remote Consultation Comments or questions are welcome. * indicates required field Name:* Email:* Telephone:* Number & Type of Govt Issued ID Card* Please reenter Patient's name and relative or caregiver name* Consent for telemedicine/remote consultation For the purpose of this consent, as defined in Telemedicine Practice Guidelines prepared by Niti Aayog and released under notification from Ministry of Health and Family welfare, Govt of India enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine; telemedicine, teleconsultation or remote consultation will mean delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities Purpose : I am aware that the purpose and benefits of telemedicine are to enable patient to get medical care by specialists when it is not possible to meet the physician personally. I give my consent for remote consultation, i.e. telephonic or online consultation through WhatsApp, SMS, e-Mail or other means, to Dr. Jayesh Kakar as under :- 01. I state, that I am requesting Dr. Jayesh Kakar from Savelegs Diabetic Foot Clinic, Hyderabad and I am not consulting /talking to the doctor from outside the country. 02. As the patient is not in a position to give his consent and I am the caregiver, I confirm that I have taken/given the permission for this teleconsultation. 03. Insufficient information : I understand that the Information transmitted may not be sufficient to allow for appropriate medical decision by the physician due to technological problem such as a. poor quality of voice, b. poor resolution of images, c. deviation in color of images, d. lack of understanding on both sides because both Dr Jayesh Kakar and patient are not face to face. 04. Security I am aware that electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient. However possible risks associated with telemedicine are: a. Security protocols may fail, causing breach of privacy of personal medical information, b. Lack of access to complete medical records may result in adverse drug interaction or allergic reactions or other judgment errors. 05. Nature of tememedicine: I have been informed regarding nature of telemedicine consultation as under : a.Details of patients medical history, examination, X-rays and test reports will be discussed with other health professionals through the use of video, audio and telecommunications technology b. Physical examination of the patient may take place from a distance using video and or electronic devices. c. Non medical technical personnel may be present in the telemedicine studio to aid in video transmission. d. Video, audio and or digital photo of the patient may be recorded during the telemedicine consultation visit. 06. eCommunication: I understand that Telemedicine involves the use of electronic communication to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education and may include: a. Patient Medical Records, b. Medical Images, c. Live two way audio and video or stored files, d. Output data from medical devices. 07. I understand that the remote consultation will be recorded concurrently on case notes and I am liable to make payment for the same. Copies of medical record will be stored by the provider and I will have access to them as per existing laws. I understand that the record will be kept confidential by the Dr Jayesh Kakar. 08. Confidentiality: I am aware that Dr Jayesh Kakar has taken reasonable and appropriate efforts to eliminate any confidentiality risks associated with the telemedicine consultation. Dissemination of any patient-identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my consent, unless authorized under existing confidentiality laws 09. I permit Dr. Jayesh Kakar to record the conversation as well as images during the consultation process and I understand that recording may be used as part of medical record. 10. History: I understand that the telephonic consultation will be based on the information furnished by me as a patient or his/her caregiver. I also understand that if any history is not revealed at that time of consultation, diagnosis made and treatment given by the doctor may vary accordingly. I undertake to provide such missing / forgotten information to the doctor as early as possible so that necessary corrections in the treatment can be made. 11. Examination : The telemedicine consultation will be similar to a routine medical office visit, except interactive video technology will allow patient to communicate with a physician at a distance. Communication using video images may not be equivalent to direct patient to physician contact, and physician may recommend a visit to hospital for further evaluation. I understand that since the doctor cannot examine the patient during remote consultation, the doctor can potentially make an error of judgement just by asking information, and may fail to take a correct decision regarding need of calling me to clinic. I undertake to attend the clinic if doctor so advises and also visit the clinic for follow up. 12. I am aware that I also have option to consult with a specialist in person if I can travel to the designated hospital or clinic. 13. Investigations: I undertake to get investigations as advised by the doctor during the consultation process and bear the responsibility to inform doctor as early as possible. 14. I understand that the record will be kept confidential by Dr. Jayesh Kakar to the best of his ability. 15. I am aware that I have asked for Dr. Jayesh Kakar to render me his services from remote location at my request. 16. I also understand that the doctor may terminate the remote consultation at any time during the process according to his professional judgement. 17. I also understand that I am also free to terminate the remote consultation at anytime. 18. Diagnosis: I might be asked by the doctor to get examined by another doctor or health care provider. I understand and agree that the online consult is solely based on the information provided by me in the absence of physical evaluation, and the physician may not be aware of certain facts that may limit the assessment and diagnosis of my condition and recommended treatment. Online consult is very different from a regular face-to-face examination and that the physician providing the consult is limited by physical distance, accordingly diagnosis will be limited and provisional, as online consult is not intended to replace face-to-face evaluation by a physician. The physician is only rendering an online consult and does not assume any responsibility for my continued medical care or treatment. I understand that there will be several limitations on advice being given by the RMP due to the very nature of this unusual approach to try and help me. I appreciate that there is no negligence, if there is any deficiency of service due to remote consultation. 19. I will not hold doctor negligent, if there is any deficiency of service due to remote consultation. 20. Advise: Dr Jayesh Kakar has agreed to give his valuable advice remotely at my request, and has explained that it may not have accuracy of the golden standard method of diagnosis after personal examination. He has done so in utmost Good Faith to help me; as due to various reasons, I cannot meet seek conventional consultation/medical help at present. 21. Education: I am aware that the provider may choose to use methods other than a verbal discussion or a written document, such as videos, interactive computer modules, audio files or other methods to help me understand the information better. 22. Prescription: I am aware that Dr Jayesh Kakar has offered me his services from remote location at my request even though Supreme Court has held that no prescription should ordinarily be given without actual examination. The tendency to give prescription over the telephone, except in an acute emergency, should be avoided. 23. Recording by patient: I am aware that I can record the consultation process either telephonically or by online video streaming or by exchanging pictures, x rays etc when I sign this consent. 24. Release: I hereby completely and irrevocably release the physician and related parent organization, and respective staff members and other healthcare professionals, insurance providers,administrators, officers, employees and directors of any and all errors and omissions, known or unknown, foreseen or unforeseen, knowingly or unknowingly, as well as all claims, actions or damages arising from or in connection with the online consult, conclusions or recommendations provided by the physician. Furthermore I agree that physician has no liability or responsibility for the accuracy or completeness of medical information submitted to them or for any errors in its electronic transmission. 25. Ability: As a condition to receiving the online consult service, I am giving above consent without any pressure or force, and I am not under influence of any drugs or alcohol while I am agreeing to this consent. I acknowledge that I have given this consent of my own free will. 26. Consideration: I am responsible for all the fees related to my online consult request. I understand that I am liable to make payment for the consultation, and I undertake to make payment on payTm / googlepay/bank transfer or any other electronic mode as advised by the doctor. 27. Query solving: I have been advised of all the potential risks, consequences and benefits of telemedicine. My health care practitioner has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. 28. Limitation: I solely assume risk of the limitation set forth herein and I further understand that no warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis. 29. Understanding: I have read and understood the written information provided above. 30. Risk: I appreciate the risk Dr. Jayesh Kakar of Savelegs Diabetic Foot Clinic is taking to help me to reduce my suffering. This consent document was issued by Dr Jayesh Kakar electronically with request to give consent electronically by clicking on “I Consent to the above” button.*
