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I have been asked by my healthcare provider to take part in a telemedicine consultation with The Madras Medical Mission and its physicians, associates, technical assistants, pharmacists, affiliated hospitals and others deemed necessary to assist in my medical care through a telemedicine consultation.

I understand the following:
1. The purpose is to assess and treat my medical condition.
2. The telemedicine consult is done through a two-way video link-up whereby the physician or other health provider at The Madras Medical Mission can see my image on the screen and hear my voice. However, unlike a traditional medical consult, the physician or other health provider does not have the use of the other senses such as touch or smell; and it may not be equal to a face-to-face visit.
3. Since the telemedicine consultants practice in a different location and do not have the opportunity to meet with me face-to-face, they must rely on information provided by me or my onsite healthcare providers. The Madras Medical Mission and affiliated telemedicine consultants cannot be responsible for advice, recommendations and/or decisions based on incomplete or inaccurate information provided by me or others.
4. I can ask questions and seek clarification of the procedures and telemedicine technology.
5. I can ask that the telemedicine exam and/or videoconference be stopped at any time.
6. I know there are potential risks with the use of this new technology. These include but are not limited to:
• Interruption of the audio/video link.
• Disconnection of the audio/video link
• A picture that is not clear enough to meet the needs of the consultation
• Electronic Tampering.
If any of these risks occur, the procedure might need to be stopped.
7. The consultation may be viewed by medical and non-medical persons for evaluation, informational, research, educational, quality, or technical purposes.
8. I understand the examination may be videotaped for internal quality review or as might be required by my health coverage plan, however the video images will only be used for those purposes unless further authorized below.
I certify that this consent has been fully explained to me. I have read it or have had it read to me. I understand and agree to its contents. I give my consent to participate in the telemedicine examination.
I, the patient, do hereby understand and state that I agree to the above consents that I have initialed as “agree” and I do not agree to any that I have initialed as “decline.”

Agree | Decline