TELEMEDICINE CONSULTATION – PATIENT’S CONSENT
(To be read and understood by Patient or Care Giver, as the case may be, and accepted by the Patient in writing, by way of Explicit Consent, prior to initiation of a Telemedicine Consultation)
1. I hereby confirm that I have:
a. Read and understood, or
b. My Care Giver has read and explained to me the below mentioned terms and conditions (hereinafter referred to as the “T&C”), which is required to be read, understood and accepted by me (in pursuance of the TM Guidelines (as defined herein below)), prior to initiation of a Telemedicine consultation.
a. “Care Giver” means and includes a family member, or any person authorized by the Patient to represent the Patient.
b. “Health Worker” means and includes a nurse, allied health professional, mid-level health provider, Auxiliary Nurse & Midwife (ANM) or any other health worker designated by an appropriate authority, and who accompanies the Patient.
c. “Telemedicine Facilitator” means Holistic Spine Clinic LLP as a technology provider.
d. “Patient” shall mean the person executing this form prior to availing of a Telemedicine consultation OR a care giver / health worker executing the form on behalf of a patient for whose benefit this consultation is being taken.
e. “Registered Medical Practitioner” or “RMP” means a person who is enrolled in the State Register or the National Register under the Indian Medical Council Act 1956.
f. “Telemedicine” means the delivery of health-care services, where distance is a critical factor, by all health-care professionals using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, with the aim of advancing the health of individuals and communities.
g. “TM Guidelines” means the “Telemedicine Practice Guidelines” issued in March 2020 by the Board of Governors of the Medical Council of India, as may be amended from time to time.
h. “TM Communication” means and includes all channels of communication with the Patient that leverage Information Technology platforms, including voice, audio, text & digital data exchange, e.g. telephone, video, devices connected over LAN, WAN, internet, mobile or landline phones, chat platforms like WhatsApp, Facebook Messenger etc., or mobile applications or internet based digital platforms for Telemedicine or data transmission systems, like skype or email or fax, or video conferencing platforms like Zoom, Teams, Meet etc.
3. I am above 18 years of age, of sound mind and am competent to consult an RMP / I am a minor below the age of 18 years, of sound mind and I am consulting a RMP along with a consenting adult, who is above 18 years of age and of sound mind.
4. By accepting these T&C and executing this Patient consent form, I agree to a medical consultation via a TM Communication and I hereby confirm that I have the legal right and ability to accept these T&C.
5. I agree and confirm that the Telemedicine facilitator and/or the RMP will need to verify and confirm my identity (and the identity of any adult accompanying me, including a Care Giver or Health Worker) and my and their name, age, address, email ID, phone number, registered ID or any other identification as may be deemed appropriate. I further confirm to provide the Telemedicine facilitator and/or the RMP any additional proof that they may require, as they deem appropriate
6. I undertake that all information which is provided to the Telemedicine facilitator and/or the RMP will be complete and valid information and nothing will be mis-stated, withheld or false.
7. I further understand, agree and confirm that a virtual consultation via Telemedicine, involving TM Communication, may necessitate the transmission of video or digital photographs of me, or electronic transfer of my medical records, as the Telemedicine facilitator and/or the RMP deem fit (at their sole discretion) and which I hereby absolutely agree to.
8. I understand, agree and confirm that the information required to be furnished by me may vary from one RMP to another, based on his/her professional experience and discretion and having regard to different medical conditions, based on the defined clinical standards and standard treatment guidelines, and I hereby agree to furnish whatever information is required in this regard.
9. I understand, agree and confirm that my records, reports, documents, images, diagnostics, data etc. (digital or non-digital) utilized in / during the virtual consultation via Telemedicine will be retained by the RMP and/or the Telemedicine Facilitator and I agree that I have no objection to the same.
10. I understand, agree and confirm that virtual consultation via Telemedicine is limited to first aid, life-saving measure, counselling and advice on referral and is NOT for any medical emergencies, life threatening conditions or for Patients requiring acute care.
11. I further understand, agree and confirm that if a physical examination, is critical information for a consultation, the RMP will not proceed with the virtual consultation via Telemedicine until I am physically examined through an in-person consultation.
12. I understand, agree and confirm that a RMP, after considering the situation and using his/her best judgment, is entitled to decide on the best tool for a TM Communication and I agree to abide by the decision of the RMP.
13. I understand, agree and confirm that during the course of a virtual consultation via Telemedicine, a RMP may seek the assistance of resident doctors / other physicians/ trained nurses of the clinic/His team and I hereby agree to the same.
14. I understand, agree and confirm that my information will be shared with other persons working at the Clinic, in relation to scheduling and billing purposes.
15. I understand, agree and confirm that a RMP shall have the final discretion on whether he/she can prescribe or diagnose by way of a virtual consultation via Telemedicine (on the basis of the information available via the virtual consultation) or not. I further agree that the determination of the RMP is final and I agree to abide by the same.
16. I understand, agree and confirm that the diagnosis or prescription provided by the RMP will be solely based on the declaration / information given by me (during the Telemedicine consultation, and in the form of Patient notes or documents uploaded and provided by me). If I provide any in-accurate or incorrect or insufficient information, which leads to a mis-diagnosis by the RMP, I hereby undertake that the RMP and the Telemedicine facilitator shall not be held responsible for the same, and I hereby absolutely release and discharge the RMP and the Telemedicine facilitator against any and all liabilities and claims.
17. I understand, agree and confirm that I am responsible for following the advise / instructions, as regards the diagnosis provided by the RMP and the treatment as advised / instructed by the RMP. If I disregard the RMP’s advice / instruction, in any manner whatsoever, neither the RMP nor the Telemedicine facilitator shall be liable in any form or manner whatsoever and they will stand absolutely released and discharged.
18. I understand, agree and confirm that it is my sole responsibility to seek emergency help or follow- up care, as recommended by the RMP or when in my reasonable opinion, it is necessary for me to obtain such help or care.
19. I understand, agree and confirm that virtual consultations via Telemedicine, as provided by a RMP will be on a “as is” and “as available” basis without any warranty of any kind, express or implied, apart from what is contained in the TM Guidelines, the Indian Medical Council Act, 1956 and the Indian Medical Council (Professional Conduct, Etiquettes and Ethics) Regulations 2002, if any.
20. I understand, agree and confirm that a virtual consultation via Telemedicine will be considered as a First Consult if (i) the Patient is consulting with the RMP for the first time; or (ii) the Patient has consulted with the RMP earlier, but more than 3 (THREE) months have lapsed since the previous consultation; or (iii) the Patient has consulted with the RMP earlier, but for a different health condition.
21. Without prejudice to the above, I further understand, agree and confirm that a RMP may, in his / her sole discretion and professional judgment, and having regard to the interest of the Patient (after taking a holistic view of the situation) determine that a virtual consultation is not appropriate for some or all of my medical or clinical needs and, accordingly, may decide not to provide virtual consultation services via Telemedicine, and I agree to any such determination of the RMP.
22. I understand, agree and confirm that neither the RMP nor the Telemedicine Facilitator nor any of its trustees, consultants, staff or employees will be held responsible for breach of confidentiality, if there is reasonable evidence that my privacy and confidentiality has been compromised as a result of technology breach or by a person other than a RMP or the Telemedicine facilitator. I further understand, agree and confirm that although the Telemedicine Facilitator and the RMP have taken reasonable steps to employ industry-standard practices and technology to ensure the protection of private and confidential information transmitted through TM Communication, even the most secure systems can be compromised and neither the Telemedicine Facilitator (nor any of its trustees, consultants, staff or employees) nor the RMP can ensure absolute security and I will not hold them liable for any such breach.
23. I understand, agree and confirm to the publication of my treatment for medical, scientific and /or educational purposes including such photographing, videotaping, televising with description or other observation, provided the pictures or descriptive texts accompanying them do not reveal my identity except for testimonial purposes.
24. I understand, agree and confirm to make immediate payments to the Telemedicine Facilitator and/or the RMP, as the case may be, of all amounts due and payable to them pursuant to the virtual consultation via Telemedicine, provided by the Clinic and/or the RMP and for all other fees, charges and taxes that may be charged / leviable in connection therewith.
25. I understand, agree and confirm that there are limitations to a virtual consultation via Telemedicine and that it cannot replace a physical examination and that a physical examination would be required if the examination requires physical touch and feel, like but not limited to - for palpation, percussion or auscultation.
26. I understand, agree and confirm that there are limitation as regards the tools used in TM Communication for virtual consultation via Telemedicine, which are as under:
i. For Video based consultation – (i) It is dependent on high quality internet connection at both ends, else it will lead to a sub optimal exchange of information; and (ii) there is a possibility of abuse/ misuse of Patient’s privacy by third parties.
ii. For Audio based consultation – (i) Non-verbal cues may be missed; (ii) Not suitable for conditions that require a visual inspection (e.g. skin, eye or tongue examination), or physical touch; and (iii) greater chance of imposters representing the real Patient.
iii. For Texts based consultation – (i) Besides the visual and physical touch, non-verbal cues may be missed; (ii) difficult to establish rapport with the Patient; and (iii) cannot be sure of identity of the RMP or the Patient.
iv. For Asynchronous (i.e., email, fax, recordings etc.) based consultation – (i) Not a real time interaction, so just one-way context is available, relying solely on the articulation by the Patient; (ii) Patient identification is document based only and difficult to confirm; (iii) non-verbal cues may be missed; and (iv) there may be delays because the RMP may not see the mail immediately.
v. I further agree that if as a result of the limitation of such tools in TM Communication, there is any mis-diagnosis, I will not hold the Telemedicine Facilitator or the RMP liable and they stand absolutely released and discharged.
27. I agree and confirm that if I avail of virtual consultation via Telemedicine from a RMP or the Facilitator, I undertake to abstain and refrain from doing the following:
i. use the virtual consultation via Telemedicine in an unlawful way or for any illegal and/or unlawful purpose;
ii. post or transmit (a) a message under a false name, or (b) any data, materials, content or information (including, without limitation, advice and recommendations) (collectively, “Information”) which (x) is libellous, defamatory, obscene, fraudulent, false or contrary to the ownership or intellectual property rights of any person, or (y) contains or promotes any virus, worm, Trojan horse, time bomb or other computer programming or code that is designed or intended to damage, destroy or otherwise interrupt or expropriate TM Communications or facilitate or promote hacking or similar conduct;
iii. impersonate or misrepresent my identity (or the accompanying adult’s identity, as the case may be) or falsely states or misrepresents my affiliation with a person or entity,
iv. tamper, hack or otherwise corrupt the administration, security, or proper function of the TM Communication;
v. use robots or scripts with the TM Communication;
vi. attempt to reverse engineer, reverse assemble, reverse compile, decompile, disassemble, translate or otherwise alter, defraud or create false results from any executable code, Information on or received by TM Communication;
vii. have anti-virus and/or anti-spyware software running that is set to override the internet browser’s cookie settings.
28. I hereby knowingly confirm that:
(I) THE USE OF THE VIRTUAL CONSULTATION VIA TELEMEDICINE IS CONDITIONED UPON ACCEPTANCE OF THESE T&C BY MY AFFIXING MY SIGNATURE TO THIS FORM AND RETURNING THE SAME TO THE CLINIC / RMP OR BY MY CLICKING ‘ACCEPT’, WHEREUPON THE T&C SETOUT HEREIN WOULD BE BINDING ON ME.
(II) BY AGREEING TO A TELEMEDICINE CONSULTATION, I HEREBY ACKNOWLEDGE THAT ALL THE T&C HAVE BEEN REVIEWED, UNDERSTOOD AND ACCEPTED BY ME, INCLUDING ITS BENEFITS AND RISKS, AND THAT MY CONSENT TO A TELEMEDICINE CONSULTATION HAS BEEN PROVIDED.
(III) NEITHER THE CLINIC NOR THE RMP, GUARANTEE THAT TELEMEDICINE CONSULTATION IS THE APPROPRIATE COURSE OF TREATMENT FOR MY PARTICULAR HEALTH CARE PROBLEM, AND IS NOT A SATISFACTORY SUBSTITUTE FOR A PHYSICAL CONSULTATION / EXAMINATION.
(IV) THE USE OF THE TELEMEDICINE SERVICES IS SUBJECT TO POTENTIAL TECHNOLOGICAL RISKS, INCLUDING INTERRUPTIONS, UNAUTHORIZED ACCESS AND TECHNICAL DIFFICULTIES, AND I FURTHER CONFIRM THAT CLINIC/ RMP MAY DISCONTINUE THE TELEMEDICINE SERVICES AT ANYTIME THEY DEEM APPROPRIATE IN THEIR DISCRETION.
(V) CLINIC’S / RMP’S RESPONSIBILITY WILL END UPON THE TERMINATION OF A VIRTUAL CONSULTATION VIA TELEMEDICINE.
(VI) NOTWITHSTANDING ANYTHING TO THE CONTRARY CONTAINED HEREIN, I UNCONDITIONALLY AND ABSOLUTELY CONFIRM, AGREE AND ACCEPT THAT (TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW) NEITHER THE RMP NOR THE CLINIC, (NOR ITS TRUSTEES, CONSULTANTS, EMPLOYEES AND STAFF) SHALL BE LIABLE OR RESPONSIBLE FOR ANY DIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, EXEMPLARY, PUNITIVE, OR INDIRECT DAMAGES ARISING OUT OF OR OTHERWISE RELATING TO THE PROVISION OF TELEMEDICINE CONSULTATION TO ME.
29. All of the T&C as contained herein shall in all respects be subject to, governed by and construed in accordance with Indian law including all matters of construction, validity and performance.
30. I agree to Holistic Spine Clinic publishing any communication or writing that indicates words of appreciation by me either in feedback form or through any other means of communication as well as my picture as Testimonial wherever deemed appropriate.
31. For the benefit of the RMP, the Clinic and its Trustees, Consultants, Employees and Staff, the Courts at Ahmedabad shall have exclusive jurisdiction to settle any and all disputes which may arise from or are in connection with these T&C and, accordingly, any legal action or proceedings arising out of or in connection with these T&C (“Proceedings”) may be brought at Ahmedabad alone. I irrevocably submit to the jurisdiction of courts at Ahmedabad.
32. I understand, agree and confirm (i) that in the event of any conflict between these T&Cs and the terms contained in the TM Guidelines, the provisions contained in the TM Guidelines will prevail; and (ii) to the extent relevant, the terms contained in the TM Guidelines will be deemed to be incorporated into these T&Cs.
33. I hereby confirm and acknowledge that I have agreed to the T&Cs, as contained herein, on my own free will and volition, after having carefully perused and considered the same, and having sought independent advice of any accompanying adult, if required, before consenting to these T&C. Upon accepting these T&C, I will not seek to dispute, deny or contest any or all of the terms as contained herein for any cause or reason whatsoever.