Skip to content
Home
About Us
Our Team
Our Services
Contact Us
Menu
Home
About Us
Our Team
Our Services
Contact Us
Book Now
Home
About Us
Our Team
Our Services
Contact Us
Menu
Home
About Us
Our Team
Our Services
Contact Us
Book Now
Informed Consent Form
Name
(Required)
Full Name
Phone
(Required)
Age
(Required)
MM slash DD slash YYYY
Gender
Male
Female
Others
Email Id
(Required)
⦁ General Information:
⦁ Tele assessment (TAC) clinics shall be ONLY on appointment basis with confirmation notified via your verified email ID. ⦁ The professional discretion of the attending Psychiatrist and team will govern TAC clinic.
⦁ Procedural information:
Telemedicine is the use of electronic information and communication technology to deliver clinical services by a health care provider to an individual at different places than the provider.. TAC clinic duration ranges from 45 to 90 minutes of detailed evaluation over initial 1-2 sessions, and each therapy sessions will last for 45 minutes and follow up psychiatry consultations for 15 – 20 minutes, similar to your regular in-person follow-ups. The clinical notes shall be written and will be saved in our e-files by the attending doctor and prescription will be send in pdf format to the registered email id. Please remember that you will undergo a ‘virtual physical examination’ based on virtual inspection but if in-person examination warrants, the online session shall be aborted and you will be asked to consult in-person or to a local Psychiatrist/Physician. The scanned copy of the prescription will be sent to your verified mail id / phone number once the TAC clinic consultation ends successfully. In case of a possible technical snag or communication failure, the Centre staff shall attempt to re-establish contact and if failed, a new appointment shall be scheduled.
You have the right to refuse or withdraw consent at any time without assigning any reason/s. Your refusal will not have any adverse effect directly or indirectly to continue your in-person care. You may revoke the consent in writing at any point of time by contacting the treating doctor. The laws that protect privacy and confidentiality of medical information also apply to TAC clinics. No (patient/patient’s family member or treating doctor) will record audio or video and covert recordings (audio or video) are considered illegal. Explicit written consent is must from all the parties prior to recording if required. Patient / patient’s family member will be responsible for the accuracy of the information shared with the doctor. Not more than one family member or any other confidante of patient’s interest shall be allowed to join TAC clinic consultation at one point in time (either at the same or from different log in place). We undertake to maintain confidentiality of the information obtained during the teleconsultation except as per clause 1.4.
⦁ Expected Risk:
In case of any side effects, stop the medications and consult local doctor immediately. In rare instances, there may be a breach in privacy by the tele-communication service providers, which is beyond the control of clinical team.
⦁ Services not included over Video Consultation:
⦁ Emergency consultation:
Under no circumstances, emergency-based TAC clinic consultations shall be entertained. If the patient’s clinical condition is unstable/severe, do not wait for TAC clinic appointment and in-person consultation at the nearest Psychiatrist or Physician at the earliest is recommended.
⦁ Proxy Consultation:
Presence of patient is a must during TAC clinic consultations and proxy consultation (i.e. family member/any others consulting for the patient instead) shall not be entertained.
⦁ Issue of any Certificate/document/medical record:
We will not be entertaining issue of any certificates or legal documents.
⦁ Data charges:
You will be responsible for payments of data charges for TAC clinic consultations that incur from your side.
⦁ All Telemedicine Consultations under TAC will be governed as per the Telemedicine Practice Guidelines 2020.
⦁ Appointment Cancellation Policy: We are committed to providing exceptional care. Unfortunately, when one patient cancels without giving enough notice, they prevent another patient from being seen. Please inform us through proper channel, atleast 24 hours before the scheduled session for rescheduling the appointment. If prior notification before 24 hours is not given, you will be charged the same consultation amount for the missed appointment. Kindly go through the Appointment cancellation policy in the website.
Declaration of consent:
I have been informed and explained about the procedure and potential risks with TAC clinic consultation by my treating doctor in my understandable language. I understand that I have the right to withhold or withdraw my consent at any point of time, without affecting any of my future treatment. I also understand that, I shall maintain privacy/confidentiality of the doctor’s consultation at my end. I am also aware that treating doctor and staff will contact me or my family member over phone for various reasons including but not limited to fixing video consultation appointment (if required). I am also aware that there may be a non-medical person (i.e., tele-technician) during my teleconsultation. I will not record audio and/or video of TAC without explicit written informed consent.
Patient’s Signature
(Required)
Aadhar Number / Driving licence/ Passport / Voters ID Number
(Required)
Family Member’s or care giver’s Name (If patient is minor )
Full Name
Family Member’s or care giver’s Signature (If patient is minor )