NAIROBI ENT CLINIC VIRTUAL CONSULTATION CONSENT FORM 2

Introduction

Telemedicine is the delivery of healthcare services when the healthcare provider and patient are not in the same physical location through the use of technology.

Electronically-transmitted information may be used for diagnosis, therapy, follow-up and/or patient education, and may include any of the following:

• Patient medical records.
• Medical images.
• Interactive audio, video, and/or data communications.
• Output data from medical devices and sound and video files.

The interactive electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Potential Benefits

1. Improved access to medical care by enabling a patient to remain at a remote site while the physician consults with the patient.
2. Obtaining the expertise of a distant specialist.
3. Utility as a screening tool during this Covid 19 pandemic.

 Potential Risks

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

1. Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the and consultant.
2. The consultant is not able to provide medical treatment to the patient through the use of telemedicine equipment nor provide for or arrange for any emergency care that I may require.
3. Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
4. Security protocols could fail, causing a breach of privacy of personal medical information.

By signing this form, I understand and agree to the following:

1. The laws that protect the privacy and confidentiality of medical information also apply to telemedicine. No information obtained during a telemedicine encounter which identifies me will be disclosed to other entities without my consent.
2. I have the right to withhold or withdraw my consent to the use of telemedicine during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment, nor will it subject me to the risk of loss or withdrawal of any health benefits to which I am otherwise entitled.
3. A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My physician has explained the alternative care methods to my satisfaction.
4. I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured. My condition may not be cured or improved, and in some cases, may get worse.
5. I am expected to avail myself immediately for any appropriate medical attention in any medical emergency or critical care situation and not attempt to use the telemedicine platform as a substitute for such conditions.
6. I am expected to avail myself within 48 hours for an in-person visit if required by the consultant, failure to do so will forfeit the virtual consultation fee.

Patient Consent To The Use of Telemedicine

I have read and understood the information provided above regarding telemedicine.

I hereby give my informed consent for the use of telemedicine in my medical care. I hereby consent to and authorize Nairobi ENT Clinic to use telemedicine in the course of my diagnosis and treatment.