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.