Teleconsultation -Covid-19 testing

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 The Patient 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 telehealth 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, The Patient's 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, the condition can't be diagnosed by the mean of teleconsultation and the patient might need to further arrange another face-to-face consultation to properly assess the condition while 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 a minority (age below 18), during the consultation process, an accompany adult of over age 18 (parent, legal guardian or next of kin) need to be in presence during the consultation and the adult have to sign at the consent form as well.

Patient Full name as shown on ID/Passport

First Name Last Name

HKID/Passport Number *

Date of birth *

Date

Email *

example@example.com

Contact Number *

Do not fill in Country and area code if it is a local number

Home Address *

Required for drug delivery purpose

Appointment

By signing this form,

The patient understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

The patient understand that the preferred date and time is not a guaranteed time commitment. The clinic will liaise with the patient to confirm the final date and time conducting the teleconsultation.

For special requests, please directly contact our staff through email: info@marinamedical.hk, or call us at 3420 6622

About COVID-19 Testing

COVID-19 is rapidly spreading worldwide. Active community transmission is occurring in overseas countries. The Department of Health has strengthened health quarantine arrangements on inbound travelers arriving from countries/regions with active community transmission.

According to the Prevention and Control of Disease Ordinance (Cap 599), we have a responsibility to notify the Department of Health if there’s any suspected or confirmed cases of infectious disease specified in the first schedule of statutory list. For more details, kindly visit www.chp.gov.hk & http://ceno.chp.gov.hk.

All patients who tested positive will be arranged by the CHP to be admitted to a public hospital for isolation and further management. The CHP will inform the patient directly for the arrangement.

Patient Signature

Clear

Guardian information ( Fill in if patient is below 18)

Guardian name

First Name Last Name

Relationship with patient

Guardian Signature ( if patient is under 18)

Clear

Teleconsultation for Covid-19 testing