PATIENT CONSENT ｜患者同意書
PURPOSE: The purpose of this form is to get the patient's consent in order to conduct teleconsultation. The patient understands and agrees that:
1. The Patient hereby authorize Marina Medical to use the teleconsultation practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.
2. Technical difficulties may occur before or during the teleconsultation sessions and his/her appointment cannot be started or ended as intended. The information transmitted may be of insufﬁcient quality to allow for appropriate medical or health care decision making.
3. The professionals can conduct interactive sessions with video call; however, The Patient understood and accepted that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
4. The Patient's current insurance may not cover the additional fees of the teleconsultation practices and the patient may be responsible for any fee that the insurance company does not cover.
5. The Patient's medical records on teleconsultation can be kept for further evaluation, analysis and documentation, and in all of these, his/her information will be kept private. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks. The electronic systems, in some instances, may fail and cause a breach of privacy and/or personal health information.
6. In certain situation, his/her condition cannot be diagnosed by the mean of teleconsultation and he/she might need to further arrange another face-to-face consultation to properly assess the condition. This current teleconsultation will still be considered as a completed consultation.
7. If a further face-to-face consultation is needed, the patient understand it is solely up to his/her own decision whether should continue.
8. If the patient is under 18 years old, an accompanying adult (parents, guardians or next of kin) must be present with the patient during the consultation and the accompanying adult must sign on the form as well.
如果患者未滿 18 歲，諮詢期間必須有陪同成人（父母、監護人或近親）在場，並且陪同成人必須在表格上簽字。