Pediatric ICU in Doddaballapur, Bangalore

Telemedicine involves the use of electronic communications to enable Hospitals/health care centres to provide healthcare services at different locations through exchange of information and for the purpose of improving patient care. I, confirm that I have received the necessary information to sign this form and I agree to take part in a live telemedicine/teleconsultation session with Manipal Hospitals.

• Interactive audio/video connection, electronic information and communication technologies shall be used for providing me with a telemedicine/teleconsultation.
• In case the information obtained via teleconsultation is not sufficient to make a diagnosis, I may be required to go to Manipal Hospitals for in-person consultation.
• Though the telemedicine/teleconsultation is private, other individuals, medical and non-medical, may be present to facilitate the consultation and that they will take reasonable steps to maintain confidentiality of the information obtained.
• A limited visual examination will take place during the telemedicine/teleconsultation and that it cannot replace a full medical examination done physically at Manipal Hospitals.
• I have the right to withhold or withdraw my consent to the use of telemedicine/teleconsultation in the course of my care at any time, without affecting my right to future care or treatment. I may also revoke my consent orally or in writing at any time.
• I may be prescribed medicines for treatment or/and diagnostic tests to further evaluate my health condition. All prescription will be sent to my registered email/phone no. Manipal Hospitals will keep a record of the consultation & prescription in my medical record.
• The telemedicine/teleconsultation services are not in any way intended to be used in case of an emergency.
• There can be potential risks with this technology e.g information transmitted may not be sufficient to allow for appropriate medical decision, the video /audio may disconnect/stop in-between, security protocols could fail causing a breach of privacy of personal medical information.
• Any relevant medical information about me including details of my medical history, examinations, x-rays, tests, photographs or other images may be transmitted /shared by Manipal Hospitals with their staff, specialist, business partners for the purpose of record, communications, feedback, enquires, follow ups, analysis etc.
• Manipal Hospitals responsibility shall terminate upon conclusion of this teleconference.
• I hereby consent that in consideration for the telemedicine / teleconsultation services rendered to me, I agree to pay the relevant charges.
• I hereby release Manipal Hospitals, its personnel and any other person participating in my care from any and all liability which may arise from authorized use of such Video / E-Consultation, Videotapes, Digital recording films and Photographs. I have read this document and understand the risk of the telemedicine / teleconsultation.
• I hereby consent to participate in a telemedicine / teleconsultation under the terms & conditions described in this document.