Consent for Online Video Consultation

I understand that my health care provider (Dr Tariq Hospital) is providing me with an online video consultation. This means that I and/or my healthcare provider or designee will, through interactive audio/video connection, be able to consult with the clinician (assigned by Dr Tariq Hospital) about my condition.

I understand there are potential risks with this technology:

1. The video connection may not work or may stop working during the consultation.
2. The video picture or information transmitted may not be clear enough to be useful for the consultation.
3. I may be required to go to the location of the consulting physician if it is felt that the information obtained via telemedicine was not sufficient to make a diagnosis.

I also understand that other authorised individuals may be present to operate the online video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained. All appropriate measures will be taken to protect my privacy, through the use of end to end encryption, though there may be risk of identification if the encryption system fails. The consultation will be recorded for quality and record keeping purposes as per the regulations of NHRA (National Health Regulatory Authority.

I understand that a limited physical examination will take place during the videoconference and that it cannot replace a full medical examination done physically at the medical centre/hospital. I have the right to ask my healthcare provider to discontinue the conference at any time. The video consultation services are not in any way intended to be used in case of an emergency.

I understand that I will undergo a general assessment by the physician and I must be forthcoming regarding all elements of my health and give full disclosure to the consulting physician.

I authorize the release of any relevant medical information about me to the consulting health care provider, staff the consulting health care provider supervises, third party payers and other healthcare providers who may need this information for continuing care purposes.

I also understand that the responsibility of the consulting provider regarding my health care will terminate upon conclusion of the teleconference.

I hereby release Dr Tariq Hospital, its personnel and any other person participating in my care from any and all liability which may arise from the taking and authorized use of such Video/E Consultation and images. I have read this document and understand the risk of the online video consultation.

I hereby consent to identify myself at the start of the consultation using a government issued Identification card with photo and participate in an online video consultation under the conditions described in this document.

I understand that the amount paid for the consultation is non-refundable and non-transferable.

As per the above conditions I am 18 years and above, I agree to undergo an online video consultation.

If a consultation is required for a minor patient, parental or legal guardian consent is required.