AUTHORIZATION AND CONSENT FOR VIRTUAL DERM CONSULT

The purpose of this form is to obtain your consent to participate in a telemedicine consultation with the following dermatology specialist: Dr Ighorodje Edesiri

  1. Purpose and Benefits. The purpose of this mode of consultation is to use telemedicine to enable clients to access dermatological care by specialists from any location without the inconvenience and expense of making a trip to the clinic.
  2. Nature of Telemedicine Consultation: The consultation will only be between the client and specialist. During the telemedicine consultation:
    1. Details of your personal and medical history will be obtained.
    2. Limited skin examination may take place.
    3. Video, audio, and/or digital photo may be recorded during the telemedicine consultation visit as this will assist in objective assessment in follow up visits.
    4. Specify if it is audio or video consultation you would like to engage in, in the comment section when placing your appointment.
    5. Pictures of client will need to be sent ahead of consultation to give the specialist some preparation before appointment time.
    6. Timing for the appointment should strictly be adhered to. Virtual Link will be cut off once the time for the consultation has been concluded.
  3. Medical Information and Records. All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Additionally, dissemination of any patient-identifiable images or information from this telemedicine interaction to the public shall not occur without your consent, unless authorized under existing confidentiality laws.
  4. Confidentiality. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation. All existing confidentiality protections under federal law apply to information disclosed during this telemedicine consultation.
  5. Risks and Consequences. The telemedicine consultation will be similar to a routine medical office visit, except interactive audio/video technology will allow you to communicate with a physician at a distance. At first you may find it difficult or uncomfortable to communicate using video/images. The use of this technology to deliver healthcare and counselling services where needed, may not be equivalent to direct patient to physician contact. Following the telemedicine consultation, your physician may recommend a referral for an in-person dermatologist for further evaluation, where deemed necessary or on request by the client.
  6. Rights. You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right of future care or treatment, and confidentiality stays covered. You have the option to consult with the nearest dermatology specialist in-person in your vicinity.
  7. Financial Agreement. This telemedicine consultation will be paid for by the client to confirm booking.
  8. Cancellation: Incase of cancellation or change of consultation time, Client will need to cancel/change the appointment time 24 hours before consultation or forfeit payment.
DECLARATION
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. I understand the written information provided above. By filling this form, I consent to the information shared within.
Patient (or person authorized to give consent) If signed by person other than client, provide relationship to client
Patient Email
Date Patient Signed
Witness Full Name
Date Witness Signed