Telemedicine Consent Form - Grace Fertility

Telemedicine eConsent Form

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Step 1 of 2

A few personal details

Name

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region

Please read carefully to understand your rights established by the Telemedicine Society of India

The purpose of this Consent Form is to obtain your consent for your participation in the Telemedicine Consultation in connection with your Natural Conception Program and/or related fertility services provided by Grace Fertility

Nature of Consult
During the Telemedicine consultation, the following may be sought of undertaken:

Details of your medical history, examinations, X-Rays, Ultrasounds, and any other relevant test reports will be discussed with other health professionals through the use of interactive video, audio, and telecommunications technology.
A non-medical technician may be present in the telemedicine room to aid in the video transmission.
Video, audio, and/or photo recordings may be taken of you during the consult and will be duly informed.

All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Note that dissemination of any identifiable images or information for this telemedicine interaction to other researchers shall not occur without your consent.
Reasonable efforts have been made to eliminate any confidentiality risks associated with this telemedicine consultation.
You may withdraw or withhold your consent to the telemedicine consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any benefit to which you would otherwise be entitled.

Date*

Signature