Patient Consent Form for Online Consultation With Doctor
I hereby understand agree and consent to the following:
I authorize the Doctors of Ortho-One to assess my medical history and to provide healthcare services on ‘as is’ and ‘as available’ basis, including administration of drugs as deemed necessary.
I am aware that healthcare services will be provided through telephonic or Internet consultation with the Doctors of Ortho-One hospital and that there will be no physical examination. I agree that the diagnosis based on telephonic consultation will be at a pre-primary level and that I will visit another doctor either as directed by the Doctor undertaking the telephonic/online consultation or a doctor of my choice for further treatment.
During the course of the treatment I will disclose sensitive personal information (“SPI”) which will include without limitation (i) physical, physiological and mental health condition, symptoms and history; (ii) medical test results in connection with the aforesaid; (iii) medical records and history..
I understand that it is my sole responsibility to communicate and provide Ortho- One and its doctors and the Professionals with detailed, accurate and complete information concerning medical, medication and other history, allergies to medications and procedures, physical, mental and other relevant symptoms and conditions, and any other information or records requested or pertinent to the diagnosis and treatment of myself or those I am authorized to represent. I understand that, as with any service, to the extent that information is not provided or, if provided, is not detailed, accurate and complete, the services provided by the Ortho-One and its doctors and the Professionals may be materially affected. I assume all risks, and assume full responsibility and waive all claims against the Hospital Ortho-One, its doctors and the Professionals for personal injury, death or damages of any kind and agrees to the extent permitted by applicable law to defend, indemnify and hold harmless the Hospital Ortho-One, its doctors and the Professionals from and against any and all claims of any nature including all costs, expenses and attorneys’ fees, which in any manner result from the failure to provide pertinent information and/or the failure to provide accurate and/or complete information as required.
I understand that the Ortho-One and its doctors will not publish and disclose the SPI to any third person or body corporate without my express written consent, except when mandated by law. I understand that Ortho-One and its doctors will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that Ortho-one and its doctors may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state if necessary.
The Hospital Ortho-One, its doctors and the Professionals will not be responsible for the authenticity of the SPI provided by me to the Hospital Ortho-One, its doctors and the Professionals. I agree that the Hospital Ortho-One, its doctors and the Professionals liability will only be limited to the professional services rendered by it and that the Hospital Ortho-One, its doctors and the Professionals does not make any guarantee, representations or endorsements or implied or express warranties with respect to the services provided by any Doctor engaged by it.
I understand there is a risk of technical failures during the tele/online consultation encounter beyond the control of Ortho-One and its Doctors. I agree to hold harmless Ortho-One its Doctors and its professionals for delays in evaluation or for information lost due to such technical failures.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that all health care treatments can have potential adverse side effects and I accept responsibility for such potential adverse outcomes. If adverse effects are noted, I understand that it is my responsibility to stop any prescription medicines or other treatment, procedure, service or product prescribed or recommended by the Hospital Ortho-One, its doctors and the Professionals and to report any adverse side-effects to the Hospital Ortho-One, its doctors and the Professionals, my primary care or specialty physician, or go to the nearest Emergency Room if I have any reason to suspect that I have a medical emergency.
I acknowledge that the Professionals shall exercise reasonable medical judgment in delivery of the Services provided, if any, but the condition for which I or those I am authorized to represent may seek a diagnosis, consultation or treatment may worsen after the Service provided, and both I and those I am authorized to represent are subject to the risks described above, including risks that the condition may worsen. I agree that I will not be entitled to a refund or recompense from Hospital Ortho-One, its doctors and the Professionals for any reason, including poor outcomes.
I understand that the Ortho-One does not provide emergency medical services. If I have a medical emergency, I should call local emergency contact number. The Ortho-One may provide me with the phone numbers and addresses of medical facilities and emergency services, but using those services is at my own risk. The Ortho-One is not responsible for the accuracy of this information or for any delay in seeking hands-on emergency treatment. By using the services of the Ortho-One I agree that I have understood all of these terms and conditions, and consent to receiving phone-based or internet-based consultation and information from the Ortho-One.
I consent and agree to submit myself to the exclusive jurisdiction of the competent court at Coimbatore only. I understand that Ortho-One is at its sole discretion to withdraw its services without any prior intimation.
I have carefully read the terms and conditions before availing the Ortho-One’s services. By subscribing/ using the services, I hereby acknowledge that I am familiar with these terms and conditions and any change or modifications that may occur from time to time. The following information shall be referred to as Personal Information: Password to the Ortho-One’s website; Name, date of birth, postal address, e-mail and telephone number; Physical health condition and medical history; mental health condition; Family’s medical condition; and Biometric information. The Ortho-One reserves the right to make changes to these terms and conditions. The terms and conditions and the services will be governed as per the applicable laws of India and the courts of Coimbatore only will have exclusive jurisdiction over all or any matters arising out of or relating to these terms and conditions or the services. The Duration of Tele/Online consultation may be restricted to 10 minutes per patient considering Ortho-One needs to cater the health care needs of a large population. *
