Teleconsultation Record & Consent
Name
NRIC/FIN
Date of Birth
-
Day
-
Month
Year
Date
Email
example@example.com
Phone
Institution
NCCS
SEMC
NUS
Other
Department
Purpose of Consult
Incident followup
Return to work followup
Questionnaire review - Biosafety, Animal Work etc
Other
Description of Incident/Injury (if any)
No of MC days
No. of Light Duty or Modified Work days and description
Consent for Teleconsultation
I hereby authorise The Occupational and Diving Medicine Centre to use teleconsultation means (eg video calls from Zoom/Whatsapp, Tigertext) for evaluating, testing and diagnosing my medical condition.
I understand that technical difficulties may occur before/during teleconsultation and my appointment cannot be started or ended as intended.
I accept that the teleconsultation sessions can be conducted via regular voice communication if technical requirements such as internet speed cannot be met.
I accept the limitations of teleconsultation and there may still be a need to have a face to face consultation at the clinic if the doctor deems it so to make a proper medical evaluation.
I agree that my medical records on teleconsultation be kept for further evaluation, analysis and documentation, and in all these, my information will be kept private. However, in the event where an incident/exposure/injury has occurred, I agree for the doctor to reveal relevant medical information when it will assist with the investigation or treatment.
Signature
Date of Submission
-
Month
-
Day
Year
Date
Submit
TO BE FILLED BY CLINIC ONLY
Reason for Consult
Medical Surveillance
Incident Report
Other
Date of Consult
-
Month
-
Day
Year
Date
Mode of Consult
Tiger Text
Face to Face
Whatsapp video
Zoom
Google Meet
Other
Details of Consult
Outcome
Discharge
TCU Open Date
Review in:
Dr Gregory Chan, Senior Specialist Physician. MCR M06367C. Signature:
Submit
Should be Empty: