Purpose: This form is intended to obtain your consent to avail medical consultation services through telemedicine services.

I understand and declare, that Telemedicine involves the use of electronic communications, which includes but is not restricted to video-calling, telephonic communication, transmission of information via electronic communications, to enable patients located at a different location to share the patients’ medical information and consult with the medical practitioners for diagnosis and treatment.

I understand and declare, that in telemedicine consultations the medical practitioner is not physically present at the location. Telemedicine allows me to consult the medical practitioners of Sangini Healthcare LLP and its Affiliates (‘Hospital’) with the help of electronic communications listed above and that my participation in any telemedicine consultation is completely voluntary. I consent to availing the services of the medical practitioner of the Hospital through telemedicine.

I understand and declare, that I am an Indian national, residing in India and availing the services provided by the Hospital remotely from a location in India.

Further, I understand, declare and consent to the following:

The medical practitioner is not physically present at the location and that the consultation involves the use of electronic communication.

The telemedicine consultation is based solely and entirely on the information furnished including but not limited to, my oral submissions, images, x-rays, text data, laboratory values, images and other diagnostic reports without any physical examination and on the assumption that information so furnished is authentic and accurate

On the advice of the consulting medical practitioner, I shall be required to get physical examination or investigation done

Medical or non-medical personnel may be present to assist me or the consulting medical practitioner for diagnosis and/ or operating video conferencing equipment.

Due to unanticipated technical reasons there may be an interruption during the telemedicine consultation or quality of transmission may be suboptimal resulting in postponement of the telemedicine consultation in which case consultation may proceed via telephonic communication.

The Hospital shall make best endeavors to protect my privacy and to keep this telemedicine consultation confidential. Though, I am made to understand that, the consultation is being videotaped, digitally recorded, filmed or photographed. However, no person shall, without my prior written consent, have any unauthorized access to such video, recording, film or photograph I understand that confidentiality is of paramount importance to the success of this telemedicine consultation and I shall therefore not, without the prior written consent of the consulting medical practitioner in any manner record audio or indulge in videography of the session

The electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data. However, I have been made to understand that, irrespective of the Hospital’s best endeavor, a breach of privacy of my personal medical information maybe possible

I have been made to understand that telemedicine consultation is not equivalent to an in-person physical consultation and the clinical risks associated with the teleconsultation process

I declare that to the best of my knowledge, the present consultation is not a situation of emergency

The Hospital would be the custodian of my medical information and that the same shall not, without my prior written consent, be used for any purpose, apart from what is consented to by me through this consent form.

I understand that the Hospital will use the information provided by me in de-identified form for research purposes.

My family members or guardian or legal representative may be contacted by the medical practitioner for safety and welfare issues.

THEREFORE, I understand that by clicking on ‘I Agree’ button, I declare that I have thoroughly read and understood the information provided regarding telemedicine.