Referral Form

I agree to take the Telehealth Consultation services provided by Medcare Hospitals & Medical Centres which involves a consultation with a certified physician who is authorized to conduct telemedicine consultation which is an interactive video conversation call.

I acknowledge I have read the guidelines on how the video conferencing technology will be used. I also acknowledge this consultation is limited to certain medical conditions for which the telehealth consultation services can be obtained and the proper procedures that shall be applied in emergency cases.

I undertake the obligation to inform the doctor about all facts important to consider while managing my/patient’s health and previous medical history/allergies/specific conditions/ disabilities irrespective of whether or not such information would have any bearing or relevance to the procedure, diagnosis or treatment/ proposed/undertaken at the hospital. I accept the fact that in case this statement is untrue, neither this hospital nor the doctors are responsible for the caused consequences.

All existing federal law laws and local regulations/ policies/ guidelines regarding access to medical information and copies of my Health Records apply to this teleconsultation. Dissemination of any patient identifiable images or information for this telehealth interaction to other entities will not take place without my consent.

Electronic systems used will be incorporate network and software security protocols to protect confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure integrity against intentional and unintentional corruption in accordance to UAE Laws and regulation.

The nature during the teleconsultation:

a. Details of medical history, examination, x-rays and tests may be discussed with other healthcare professionals with interactive videos, audio and telecommunication technology.

b. Audio and/ or photo recording may be taken for accurate diagnosis, treatment and quality control.

Responsible and appropriate efforts have been made to eliminate any confidentiality risks associated with the teleconsultation and all existing confidentiality protections under UAE federal laws and local regulation apply to information disclosed during this teleconsultation.

I understand I may withhold or withdraw consent to teleconsultation at any time without affecting my right to future care or treatment.

I understand the benefits of the telemedicine consultation such as Improve access medical care by enabling a patient to remain in their home, more efficient medical evaluation and access to expertise from distant specialist.

I understand there are possible risks of an incomplete or ineffective consultation because of the technology, and that if any of the risks occur, the consultation may terminate. The risks may include:

a. Information transmission may not be sufficient (e.g. poor resolution of images) to allow appropriate decision making by the consulted physician

b. Delays in medical evaluation and treatment could occur due to deficiencies or failure of equipment

c. In rare instances, security protocol could fail causing a breach of privacy of personal medical information

d. In rare cases, a lack of access to complete health records may result in adverse drug interaction, allergic reactions or other judgement errors

I shall not hold the Medcare medical center authorities legally or financially responsible for any kind of loss or damage sustained by the procedure.

I understand the risks, consequences, benefits, and alternatives of the telemedicine consultation. I have been provided with enough information in a language that I can understand, to make an informed decision and I agree to have the Telehealth consultation Services.

I agree to give my consent by ticking the below box knowingly, freely and voluntarily and agree to bind by its terms.

In case the patient is unable to give consent/ is a minor the legal guardian /representative shall give consent on behalf of the patient and accordingly all understandings, consents and acknowledgments mentioned above shall be deemed to be consented by the patient.