Online Consultation Consent Form

  1.  I understand and confirm that I agree that the doctor may engage via a telehealth consultation with me.
  2. I understand that the consultation will be done via video/internet conferencing technology.
  3. The purpose of the telehealth consultation is to assess and treat my condition, subject to the information provided by me.
  4.  The telehealth consultation is done through a two-way video link-up whereby the practitioner can see the patient’s image/s on the screen and hear his/her voice.
  5. The consultation will take an average of 15-20 minutes but the patient may at any time ask that the telehealth consultation be stopped.
  6. I acknowledge the risks of telehealth consultation in respect of the technology use or assessment made by the practitioner when vital information regarding the problem is not disclosed by me
  7. Any paperwork exchanged will likely be provided through electronic means.
  8. During the telehealth and/or telemedicine consultation, details of my medical history and personal health information will be discussed through the use of interactive video.
  9. Any advice and/or prescription of medication will be in accordance with the SAHPRA and AHPCSA guidelines.
  10. I take full responsibility to settle the consultation fee in full prior to the start of the online consultation process and proof thereof to be sent through to the practice.
  11. I understand and agree that the consultation may be recorded.

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