Consent Form

PURPOSE

The purpose of this Consent Form is to obtain your consent to participation in telemedicine consultaion in connection with the following procedure(s) and / or service(s): S

NATURE OF CONSULT

During the telemedicine consultation, the following may be sought or undertaken:

• Details of your medical history, examinations, x-rays, and test will be discussed with other health professionals through the use of interactive video,audio, and telecommunications tecnhology.

• Your physical examination may take place.

• A non-medical technician may be present in the telemedicine center to aid in the video transmission.

• Video, audio and/ or photo recordings may be taken of you during the consult.

• 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 or other entities 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 of treatment or risking the loss of withdrawl of any benefit to which you would otherwise be entitled.

UNDERTAKING

• I have been advised of all the potential risks, consequences and benefits of telemedicine.My registered medical practitioner has discussed with me the information cited above, and I have understood the terms of this telemedicine consultation.

• I agree/ do not agre to participate in telemedicine consultations for the procedures/s and or service /s discussed above.