In signing this Consent Form, I submit that I have fully read and understood the following and that I fully and freely consent to the same:

1. Telemedicine Consultation is conducted with use of telephone, cellphone, computer, or other similar electronic gadgets that will enable me as a patient to communicate with my doctor/s for the purpose of diagnosis, treatment, management, education, and follow-up care when a face-to-face consultation is not possible.
2. This Telemedicine Consultation may involve live two-way audio and video, patient pictures, medical images, patient’s medical records and other things that may be pertinent to the consultation.
3. I may be asked to give my history, share my laboratory test and imaging results, and other documents pertinent to my health concerns. Moreover, I may also be asked to show certain parts of my body which may be considered necessary to form a diagnosis.
4. It is my right to ask non-medical staff to leave the consultation room and to be assisted by a family member or a guardian.
5. The systems of RMCI will utilize network and software security protocols to protect my patient data, including identity, privacy, and confidentiality.
6. There are potential risks in this Telemedicine Consultation, including technical difficulties, interruptions, poor transmission of images leading to misdiagnosis and consequently mistreatment, no access to paper charts or medical records, delays and deficiencies due to malfunction of electronic equipment and software, as well as unauthorized access leading to breach of data privacy and confidentiality.
7. The clarity of the images, audibility of sound, internet speed, and background noise may affect the quality of the Telemedicine Consultation. Clarity and quality of the personal monitor and camera of patient may also be a factor in coming up with a proper diagnosis.
8. By participating in this Telemedicine Consultation, I acknowledge that a physician-patient relationship is formed with the doctors involved, at my request.
9. At any time and for any reason, I may terminate the Telemedicine Consultation and the physician-patient relationship.
10. In case of an urgent medical concern, my doctor may refer me to the nearest hospital in case he or she deems my concern to be urgent and would warrant immediate action and physical management by doctors. My doctor’s responsibility in this case ends with the conclusion of that particular Telemedicine Consultation.
11. I agree to share my personal data with the clinic or hospital staff of my doctor in order to facilitate scheduling of my consultation and for billing purposes. I agree not to record in video or audio format nor divulge the details of my consultation in compliance with the Data privacy Act of 2012.

I have read this form in its entirety and I fully understand its contents, including the risks and benefits of telemedicine consultation. I was also given the opportunity to ask questions regarding the contents thereof and my questions were satisfactorily answered in a language that can understand.

I am executing this separate consent for RMCI and my doctor to make and archive a video recording of my Telemedicine Consultation in accordance with the Health Privacy Act of 2012. This process is similar to keeping my data in paper charts in the clinic and will be stored for at least 15 years. I trust that RMCI and my doctor will do their best to keep my medical data safe from theft, corruption, loss, illegal use, and/or breach.

In this regard, I understand I may obtain a copy of my Telemedicine Consultation upon my request.

While all Telemedicine Consultations are considered confidential, I understand that given the nature of technology, despite using appropriate measures, RMCI or my doctor cannot guarantee the safety of my personal data from unintentional data loss, corruption, or hacking. In this regard, I agree to hold RMCI and my doctor free and harmless from any liability which may arise from the loss, corruption, or hacking of my medical data caused by a breach in security.