My Doctor | Home

Patient Details

Full Name*

Address

Email*

Mobile Number*

Clinic

Profile Photo

Terms and Conditions

Accept

Terms and Conditions

I understand that telemedicine is the use by a health care provider of communication technologies available such as the internet for delivery of health care services via audio and video regardless to the location of the parties in communication.I hereby authorize Health Care Services to use the My Doctor telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.

I understand the benefits with the use of telemedicine, as well as its limitations whereas there can be no guarantee to the results of all treatments made through this medium. I understand that technical difficulties may occur before or during the My Doctor telehealth sessions and my appointment cannot be started or ended as intended. I understand the limitations with the use of telemedicine where it cannot be fully equal to face-to-face mode of treatment and such delays may incur due to possible cases of intermittent communication that may arise and which the telemedicine service provider is of no fault.

I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

I understand that my current insurance may not cover the additional fees of the My Doctor telehealth practices and I may be responsible for any fee that my insurance company does not cover.

I agree that my medical records on My Doctor telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

I understand that there are state laws that help protect my privacy by standardizing confidentiality and information security that apply to My Doctor telehealth and telemedicine consultations such as HIPAA. However, in case my insurance need access to my medical information, I hereby grant release of information requested to my insurance provider and/or its representatives.

I understand that my participation is voluntary and I have the right to withhold, or withdraw my consent to the use of the telemedicine anytime. I understand that my withdrawal does not affect any future treatment with the provider.

I am aware and shall solely be responsible for any charges incurred with the use of telemedicine and shall inform the telemedicine service provider the mode of payment I shall prefer.

By signing this form, I affirm my voluntary consent to this telemedicine engagement. I understand that each item above was explained to me. I was given the opportunity to ask my questions and the questions were answered accordingly and to my satisfaction

Registration