I hereby state that:

1. I am single/married, of legal age, and a Filipino.

2. I understand that telemedicine consultation (“teleconsultation”) is healthcare consultation carried out remotely using audiovisual telecommunications between doctor and patient;

3. I understand the challenges and difficulty of seeking a direct or face-to-face medical care given the strict home quarantine regulations presently imposed by the Philippine government during this COVID – 19 pandemic;

4. To address said difficulty, I consent and authorize the following “Doctor” or his qualified representative, to provide me with a teleconsultation for my medical concerns/needs;

                Name of Doctor

                Name of Online Moderator

                Consultation Schedule

                Name of Doctor

                Name of Online Moderator

                Consultation Schedule

5. I further accept and confirm the following rules and regulations regarding my teleconsultation with the Doctor:

    a. Setting-up of a teleconsultation:

         i. The patient shall download the (1) VIBER app (free of charge) and Facebook Messenger app (free of charge) on his/her chosen device which will be his/her medium of communication with     the doctor during the teleconsultation.

        ii. The patient shall contact World Citi Medical Center through Facebook (www.facebook.com/WorldCitiMedicalCenter) or call 8913 8380 loc 149 to set an appointment with the Doctor based on the schedule of telemedicine hours.

       iii. The patient shall be given a slot for his/her teleconsultation with the Doctor for a maximum period of Twenty (20) minutes. Should the patient want to have more than 20 minutes, he/she must inform the online moderator before the actual consultation and shall be subject to the Doctor’s availability.

      iv. Payment must be made via online brank transfer, G-cash or PayMaya before the scheduled consultation.

      v. The online moderator shall directly coordinate with the patient and Doctor for his/her scheduled teleconsultation.

b. Nature of the teleconsultation.

    a. Details of the patient’s medical history shall be discussed by the patient and/or his/her guardian with the Doctor using Viber or Facebook Messenger.

    b. Since there will be no actual or physical examination of the patient by the Doctor, the Doctor shall have the right to request the patient and/or his/her guardian to send a video or clear picture of  the patient’s symptoms during the teleconsultation.

    c. The patient shall not record any video, audio and/or digital photographs for the duration of the teleconsultation. In case such recording is done, the teleconsultation shall be rendered ineffective and shall not, at any instance, bind the Doctor.

c. Prescription of Medicines. The Doctor shall prescribe the medicines needed by the patient based on the teleconsultation. After the teleconsultation, the prescription shall be sent by the Doctor to the patient via Viber.

d. Risks and Consequences. The teleconsultation is an alternative measure to medical office visits using video messaging. However, the telemedicine may not be considered as equivalent to direct patient-to-physician contact. The Doctor shall have the prerogative to recommend that the patient visit the nearest hospital for further evaluation after the teleconsultation.

e. The Patient’s Prerogative. The patient may suspend or end the teleconsultation with the Doctor at any time during his/her slot, without affecting his/her right of future care or treatment. The patient may likewise opt to consult with another doctor in person, should the Doctor deem that a face-to-face consultation between the patient and a medical professional is necessary.

6. I have been advised of all the potential risks, consequences and benefits of teleconsultations and I have read and understood the information provided above which was explained to me by the Doctor in the language I am familiar with. I have been given the opportunity to ask questions about the foregoing information and all my questions have been properly answered.

7. I hereby execute this Form willingly and voluntarily prior to or at the start of the teleconsultation.