Online Consult Patient Telemedicine Consent, Disclaimer and Release Terms

I hereby attest that I have requested an online consult for me with a physician who is on the medical staff of Avon Medical Practice Limited (“Avon Medical”).

Via this consult, the Avon Medical physician will reach his or her conclusions regarding my medical diagnosis based solely on the information provided by me to Avon Medical.

To facilitate Avon Medical’s Physician’s online consult and for Avon Medical’s physician providing an opinion regarding my diagnosis, I authorize the release of any information pertaining to my health including medical history, pathology, laboratory and diagnostic results to Avon Medical’s  physicians. Avon Medical is authorized, at its election, to obtain any of such records and information upon request.

However, I understand that there may be a charge for copying and handling my medical records and agree to be solely responsible for such charges.

In addition, I understand and agree that:

1. Avon Medical’s online consult is solely based on the information provided by me or through my authorized release, in the absence of a physical evaluation, the Avon Medical  physician may not be aware of certain facts that may limit or affect his or her assessment or diagnosis of my condition and recommended treatment.
2. The Avon Medical online consult is very different from a regular face-to-face examination and that the Avon Medical physician providing the consult is limited by the written information and imaging provided by me or upon my authorized release. Accordingly, the diagnosis I will receive is limited and provisional.
3. An online consult is not intended to replace a full medical face-to-face evaluation by a physician.
4. I will not have direct contact with the Avon Medical physician rendering the opinion unless I decide to travel to any Avon Medical health care centre for an evaluation afterwards.
5. The Avon Medical’s physician’s opinion and conclusions will be communicated directly to me to manage my medical needs.
6. I am responsible for all the expenses related to my online consult request including, but not limited to where applicable Consultation fees, medical report translation fees, and material shipment fees
7. My medical information will be handled with strict confidentiality, privacy and security; however, I understand there are risks associated with any electronic transfer process from one location to another.
8. I have received a copy of Avon Medical’s Notice of Privacy Practices.
9. I solely assume the risk of the limitations set forth herein, and I further understand that no warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.