Introduction:
Teleconsultation uses electronic communications as an alternative for healthcare providers at different locations to continue providing patient care.
Expected Benefits:
- Improved access to medical care by enabling patients to remain in the remote site while the physician obtains results and consults.
- Efficient medical evaluation and management.
- Obtaining expertise of a distant specialist.
Possible Risks:
As with any medical procedure, there are potential risks associated with the use of teleconsultation. These risks include, but may not limited to the following:
- Information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision-making by the physician; and
- In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
By signing this form, I understand the following:
- I understand the laws that protect privacy and the confidentiality of medical information also apply to teleconsultation, and that no information obtained in the use of teleconsultation which identifies me will be disclosed to the staff of the company other than the Dermatologist without my consent.
- I understand the variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.
- I understand that teleconsultation may involve electronic communication of medical practitioners of Shinagawa Lasik & Aesthetics Clinic who may be located in other areas.
- I understand that it is my duty to inform my Dermatologist of electronic interactions regarding my care that I may have with other healthcare providers.
- I understand that I may expect the anticipated benefits from the use of teleconsultation in my care, but that no results can be guaranteed or assured.
- I understand that in case of emergency or any serious/threatening situations concerning my skin condition, I will proceed to the hospital for immediate care.
- I understand and accept that this service involves a fee of PHP 800.00 for the Derma Teleconsultation, which requires me to pay at least 3 days prior to the scheduled appointment.
- I also understand and accept that should I wish to cancel the appointment 2 days before the Derma Teleconsultation, the service value is non-refundable.
- Furthermore, I agree and consent that the teleconsultation will be recorded for documentation and educational purposes only and shall become property of Shinagawa Lasik & Aesthetics for a period of one (1) year. In case the Clinic shall use my photos/videos for purposes other than those mentioned or an extension on the use of my photos/video, a written consent must be obtained from me.
I have read and understood the information provided above regarding teleconsultation, have discussed it with my physician or such assistants and/or staff as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of teleconsultation in my medical care.
I Do Not Agree
