I give my consent for remote consultation, i.e. telephonic or online
consultation through WhatsApp, SMS, e-Mail or other means, as under :-
01. I state, that I am not talking to the doctor from outside the country.
02. I understand that there may be technological problem during
consultation e.g. poor quality of voice, deviation in color of images or lack
of understanding on both sides because both doctor and patient are not
face to face.
03. I understand that the remote consultation will be recorded concurrently
on case notes and I am liable to make payment for the same.
04. I permit United Medicity to record the conversation as well as images
during the consultation process and I understand that recording may be
used as part of medical record.
05. I understand that the telephonic consultation will be based on the
information furnished by me as a patient or his/her relative. I also
understand that if any history is not revealed at that time of consultation,
diagnosis made and treatment given by the doctor may vary accordingly. I
undertake to provide such missing / forgotten information to the doctor as
early as possible so that necessary corrections in the treatment can be
made.
06. I understand that since the doctor cannot examine the patient during
remote consultation, I undertake to attend the clinic if doctor so advises and
also visit the clinic for follow-up.
07. I undertake to get investigations as advised by the doctor during the
consultation process and bear the responsibility to inform doctor as early as
possible.
08. I understand that the record will be kept confidential by United Medicity
09. I am aware that United Medicity has offered me his services from
remote location at my request even though it is under the purview of
culpable negligence as per the decision taken in Martin F D’Souzza v/s
Mohd. Ishfaq.
10. I will not hold doctor negligent, if there is any deficiency of service due
to remote consultation.
11. I am giving above consent without any pressure or force, and I am not
under influence of any drugs or alcohol while I am agreeing to this consent.
12. Patient will make payment on PayTM, Google Pay, or by any other real-
time online payment mode as advised by the doctor.
Please send it back with signature, or send “I AGREE” reply on the post.
