CONSENT FORM

In line with the Doctor Anywhere Application as a Tele-Consultation/Tele-Medicine platform, ONET will
be sharing the following personal information to Maxicare, which will form part of the team that will work
under the said platform. Enumerated below are the data or information that are to be collected from you:
1. First Name
2. Last Name
3. Middle Name (if applicable)
4. Gender
5. ONET Employee Number
6. Email Address (ONET Email address)
7. PRC License Number
8. Doctor Profile Description
- Educational Background (name of school; year graduated)
- Years of practice
- Work experience (specify areas of practice)
- Languages spoken
9. Specialization

The processing of these personal information is for the purpose of registration or enrollment to Doctor
Anywhere. However, the only information which will be reflected in the website will be the doctor’s name,
specialization and profile description. Pursuant to the requirement of the Doctor Anywhere App, your
photo will be published/posted in the Application, which shall be acquired through you or through an
assigned photographer. No sharing of such personal information shall be done unless accompanied by the
consent of the concerned doctor.

 Photo below serves as a reference/basis as to how the details would appear upon
posting/publication regarding the Dr. Anywhere project.
Kindly mark with a ( ) the appropriate box indicating your consent to the processing of the above-
mentioned personal information
 YES, I allow Maxicare to process my personal information relating to the registration or enrollment
to Doctor Anywhere
 NO, I do not allow Maxicare to process my personal information relating to the registration or
enrollment to Doctor Anywhere

Jay-Ann Alcidera
___________________________________
Doctor’s signature over printed name