Informed Consent

.,

having

ATHS

UHID

in my full senses, without any coercion and

unreservedly do hereby give my informed consent and execute informed choice to
undergo

submit

my.

Mr.

Mrs.

/Mast.

/Miss, to undergo Tele Medicine (TM) / Remote Patient Care

(RPC) with ATHS and declare as follows

That the contents of this document are explained to me in my preferred

language _____________, which I understand well.

That I have right to withdraw this consent at any time during the process of
TM / RPC, without giving any explanation and without affecting my right to

future care or treatment, as that existed before withdrawing this consent.

That the healthcare services provided herein comply with laws and
regulations concerned with privacy and confidentiality of Health Information

(HI).
That my HI will be used for research, analysis and publication without

identifying my individual/ personal details.

That TM / RPC cannot be compared with comprehensiveness and outcomes of
physical consultation with HCP. TM / RPC is used as an supplement rather
than replacement of physical consultation. TM / RPC is used in situations
where timely and cost effective accessibility to appropriate HCPs is a

challenge and I am in such a situation.

That TM / RPC is a process wherein HI / video conferencing (VC) is made
available to remotely located Health Care Professionals (HCPs) through new
technologies for providing healthcare services. Provision of healthcare

services is entirely in accordance with such HI / VC.

That The HCP may contact / consult me through telephone / VC.
That the liability of TM / RPC service provider is limited to appropriate

interpretation of HI / VC that is presented to that HCP.

That service provider is not liable for complete, partial loss of HI/VC and/or
distortion of the same during the transfer / presentation, due to technology

failure.
That submitting this informed consent online is equivalent to my
signing this informed consent document.

That after understanding the contents of this informed consent and after
clarifying all my doubts, I have signed / submitted this informed consent to
execute my informed choice. At any point of time, now and/or in future, I will
not hold and/or caused to be held the concerned HCPs, staff of ATHS and/or
ATHS responsible/liable for not achieving the expected outcome(s) of the TM
/ RPC and/or for achieving undesired complications and I do hereby relieve
them of all such liabilities.

Sig. Of the witness

Sig. of patient/patients representative

1. Name
Name..

Date.

2. Name
.
Date.

Sig. Of the person obtaining the consent

Name .

Date ..

Date

Relationship