I understand that I have chosen to engage in a video consultation with the purpose of assessing and treating my medical condition and/or obtaining general medical advice.
I confirm I understand how video consultation technology will be used and this consultation will not be the same as a direct patient/healthcare provider visit since I will not be in the same room as my healthcare provider.
Since my doctors do not have the opportunity to meet with me face-to-face, they must rely on information provided by me or my onsite healthcare providers. Mediclinic doctors cannot be responsible for advice, recommendations and/or decisions based on incomplete or inaccurate information provided by me or others.
I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my telehealthcare provider (Mediclinic) or I can discontinue the video consultation if it is felt that the connection is not adequate for the situation.
I understand that this service is solely provided by Mediclinic. My insurer and/or TPA are not directly involved in providing medical consultations and hold no liability for any claim, from any party, arising directly or indirectly from the services provided by Mediclinic.
I understand that I can ask that the telemedicine exam and/or video conference be stopped at any time and for any reason.
I understand that my healthcare information (for example but not limited to, diagnosis code and description along with procedures and medications , family history, medical history, allergies, etc )may be shared with other individuals for claim adjudication and processing, scheduling and billing purposes. Others may also be present during the consultation other than my telehealthcare provider and consulting healthcare provider in order to support the technology and video platform. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following:
a)omit specific details of my medical history/physical examination that are personally sensitive to me.
b)ask non‐medical personnel to leave the video consultation room: and or
c)terminate the consultation at any time.
I understand that I may benefit from telehealth, but that results cannot be guaranteed or assured. Additionally, I understand that telemedicine-based services and care may not be as complete as in-person services. I also understand that if the telemedicine physician believes I would be better served by another form of consultation (e.g., in-person services) I will be asked to visit a clinic, hospital, GP, or specialist who can provide such services in my area.
I understand and am aware of the alternative treatment options available to me, and I am choosing to participate in a video consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting healthcare provider.
I understand that the service is not intended for emergency consultations and I am aware that I need to contact local emergency services in case of any doubt. In an emergent consultation, I understand that it is my responsibility to advise my local practitioner and that the telehealth provider’s responsibility will conclude upon the termination of the video conference connection.
I understand that I will not receive any royalties or other compensation for taking part in this telemedicine consult.
I understand that if I have any questions regarding the risks, benefits and alternatives I am able to contact Mediclinic support staff for detailed clarification. I understand the information will be provided to me in a language I understand.
These risks include, but may not be limited to:
In rare cases, information transmitted may be insufficient for healthcare decision-making.
Disruptions can occur due to failures of electronic equipment or internet connection.
In rare cases, a lack of access to full and complete health records may result in adverse drug interaction or other errors.
In rare cases, security breaches may occur causing a breach of confidentiality.
I understand that I have a right to access my medical information and copies of medical records in accordance with UAE law. Furthermore, I understand that the laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my call is generally confidential.
I understand that as per UAE law, I can lodge a complaint against my telehealthcare provider through the following channels:
a)To Mediclinic Middle East by sending an email to firstname.lastname@example.org
b)To the Dubai Health Authority by visiting http://mc.dha.gov.ae
I understand that I have the right to withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
By checking the box and beginning the video consultation, I certify that:
I have read or had this form read and/or had this form explained to me.
I fully understand its contents including the risks and benefits of using the service.
I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
I freely give consent and volunteer to engage in this telemedicine consultation.
I authorize Mediclinic Middle East and its doctors and physicians to review my medical details, discuss my health with me, and provide treatment advice as necessary.
I understand that the calls may be recorded for quality assurance and training purposes.