Telemed Consent and Waiver
This document shall be known as Terms & Conditions of Telehealth / Telemedicine.
Please read the following terms and conditions carefully as it sets out the terms of a legally binding agreement between you (the person requesting the Telehealth / Telemedicine consultation and anyone else who participates in the Telehealth / Telemedicine set up by the person requesting the consultation by submitting their photo id), and Doc Gautham’s Neuro Centre and Sakthisri Healthcare Solutions (of which Doc Gautham’s Neuro Centre is a unit).
By requesting an appointment for telemedicine / telehealth / video consultation through this website and by submitting your photo identification, you acknowledge that you have read / have had the terms hereunder read out to you in your language, and that you understand them, and agree to be bound by them.
Terminology used in this agreement:
Telehealth is “The delivery and facilitation of health and health-related services including (telemedicine), medical care, provider and patient education, health information services, and selfcare via telecommunications and digital communication technologies.
Telemedicine is “The delivery of health care services, where distance is a critical factor, by .. health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease……in the interests of advancing the health of individuals….”
“Doc Gautham’s Neuro Centre” hereunder includes Dr. Gauthamdas Udipi, and doctors, healthcare personnel and the staff of Doc Gautham’s Neuro Centre.
“Healthcare provider” hereunder includes Dr. Gauthamdas Udipi, and doctors, healthcare personnel and the staff of Doc Gautham’s Neuro Centre.
“I”, “me”, “my” hereunder refers to the person requesting Telehealth / Telemedicine consultation / services from Doc Gautham’s Neuro Centre, and includes any or all persons who have participated in the telehealth and telemedicine consultations with Doc Gautham’s Neuro Centre after the first request for a telehealth / telemedicine consultation with Doc Gautham’s Neuro Centre through this website.
“Patient” hereunder refers to the person who has requested telehealth / telemedicine consultation through this website and is undergoing telehealth / telemedicine consultation and / or treatment at Doc Gautham’s Neuro Centre.
Technology used for telehealth and telemedicine:
Multiple technologies can be used to deliver telemedicine consultation of which the most common are : Video, Audio, or Text (chat, messaging, email). Electronic systems used for telemedicine consultation will attempt to incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. However it is not foolproof.
There are possible risks due to the technology used. These risks include, but may not be limited to clause (7) hereunder.
Terms of this agreement:
(1) Assessment: The type and extent of services that I will receive at Doc Gautham’s Neuro Center through telemedicine / telehealth consultation will be determined following an initial assessment and discussion with me through telemedicine / telehealth consultation , and any other person(s) through telemedicine / telehealth technology, and may include lab, scans, and other investigations and reviews that the doctor determines as necessary to achieve the goal of determining the best course of treatment.
(2) Limitations: Telemedicine / Telehealth services are by appointment only and these consultations are not suitable for help during a crisis or emergency. The healthcare provider contacted during a set appointment would evaluate my need and context and guide me about the most suitable option for treatment / intervention in that context (medicine / psychometry / telepsychotherapy/ in-person psychotherapy / emergency services with some other provider etc.)
(3) I understand that video/audio consultation has its own limitations as compared to in-person sessions and some details could potentially be missed out despite the therapist’s best efforts. While all attempts will be made to arrive at an appropriate diagnosis and treatment, only a limited evaluation may be possible through telemedicine, and any diagnosis and treatment based on such limited examination may sometimes be erroneous due to no fault on the part of the healthcare provider involved in the consultation;
(4) Duration of treatment: Typically, treatment is provided over the course of several weeks or longer and the duration depends on the progress and my cooperation;
(5) Information gathering: During the course of treatment it may be necessary for the healthcare provider to communicate with others who may be required to provide more information or support for diagnosis and treatment; I may be required to go to the location specified by the consulting doctor / staff of Doc Gautham’s Neuro Centre if it is felt that the information obtained via telemedicine is not sufficient to make a diagnosis or deliver proper care and treatment.
(6) Risks: While medication and/or therapy may provide significant benefits, it may also pose some risks. While all attempts will be made to minimize / avoid such risks there are still chances of the risks occurring, which include, but may not be limited to those listed below:
a. Uncomfortable effects of medicines.
b. Adverse effects of medicines.
c. Drug interaction with medication that the patient is already taking (allopathic, homeopathic, siddha, naturopathic or any other system of medicine).
d. Uncomfortable thoughts and feelings elicited by Psychotherapy.
e. Recall of troubling memories and emotions during psychotherapy.
f. Lack of access to complete medical records by the healthcare provider may result in adverse drug interactions or allergic reactions or other judgment errors;
(8) There are possible risks due to the technology used. These risks include, but may not be limited to the below:
a. The video or information transmitted may not be sufficient to allow for appropriate medical decision making by the physician and consultant(s);
b. Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
c. Security protocols could fail, causing a breach of privacy of personal medical information;
d. The video connection may not work or that it may stop working during the consultation.
e. Other individuals may be present to operate the equipment
(9) Release of information: By submitting a request for telemedicine / telehealth consultation through this website I authorise the release of any relevant medical information about me to the consulting health care provider, any staff the consulting health care provider supervises, third party payers and other healthcare providers who may need this information for continuing care purposes.
(10) Payment: I understand that these consultations will be charged and that payment must be made upfront before the consultation / treatment is initiated. Payment may be only for consultation or for the treatment package including any or all of the following components: doctor’s consultation, medicines, counselling, therapy, and testing as required. This will be specified in the payment request. Consultation / treatment package will be initiated only on realization of the payment. I understand that I am free to refuse to undergo the telemedicine / telehealth consultation if the charges are not acceptable to me. By paying the charges I agree to them and also agree not to contest them at any future date after the telehealth / telemedicine consultation that was charged for.
(11) Communication difficulties: I understand that if there are any difficulties in communication during the session, it will be terminated and a new appointment will be scheduled. I understand that I have the freedom to withdraw from these sessions at any time if I wish. I understand that Doc Gautham’s Neuro Centre may also temporarily stop or discontinue these audio/video sessions/recommend any other method or line of treatment if either of us experience any difficulty in the process and in my best interest.
(12) Confidentiality and Recording: I understand that telemedicine / telehealth consultation is strictly confidential. I agree to use a secure line/connection for these consultations, in a relatively quiet and private space. I understand that Doc Gautham’s Neuro Centre will not audio or video record the session (either on mobile, using an app or online) and will not share the proceedings of this consultation with any other individual or agency. However, with my consent, my Doc Gautham’s Neuro Centre could use it to have their work supervised or for training of professionals. Apart from this, the details of the consultation would be shared only with a court of law, if mandated. Records of the telemedicine / telehealth consultation will be maintained by Doc Gautham’s Neuro Centre and stored in a safe location. I also undertake that the proceedings of these consultations are not to be recorded, shared or disseminated by me or my relatives / other contacts to any third person or through print, physical, digital, social or any other media, and that any sch recording or sharing or dissemination will attract legal action with suitable penalty / compensation for damages caused by such recording or sharing to Docgautham’s Neuro Centre / Sakthisri Healthcare Solutions.
(13) Responsibility For Adverse events:I agree to keep Dr. Gautham / the staff of Doc Gautham’s Neuro Centre informed of any new symptoms that develop during the treatment so that the doctor can evaluate whether it is an effect or side effect or adverse effect and manage it accordingly, failing which there may be unforeseen effects. I understand that the healthcare provider would use professional discretion to provide required recommendations about the type of professional service that may be required at any given point of time.
(a) I agree to not hold Sakthisri Healthcare Solutions, Doc Gautham’s Neuro Centre, Dr. Gauthamdas Udipi and the personnel at Doc Gautham’s Neuro Centre responsible, should any adverse events, such as lack of improvement, deterioration or situations of potential risk of harm to self or others, occur during or as a result of video/ audio consultation. I understand that in such situations I may be advised to obtain treatment at the nearest available mental health or emergency service. I hereby accept responsibility and agree to assume any risk that is associated with participating in the telemedicine / telehealth consultation and undertaking any treatment that arises therefrom, and release Sakthisri Healthcare Solutions, Doc Gautham’s Neuro Centre, Dr. Gauthamdas Udipi and the personnel at Doc Gautham’s Neuro Centre from any and all claims of damage and loss that may be a result of the participation
(b) By submitting a request for telemedicine / telehealth consult through this website I hereby agree to assume all responsibility for adverse event that is associated with participating in the telemedicine / telehealth consultation and undertaking any treatment that arises therefrom, and release Sakthisri Healthcare Solutions, Doc Gautham’s Neuro Centre, Dr. Gauthamdas Udipi and the personnel at Doc Gautham’s Neuro Centre from any and all claims of damage and loss that may arise as a result of participation in the telemedicine / telehealth consultation and the treatment and services received thereafter.
(c) By submitting a request for telemedicine / telehealth consultation through this website I hereby release Sakthisri Healthcare Solutions, Doc Gautham’s Neuro Centre, Dr. Gauthamdas Udipi and the personnel at Doc Gautham’s Neuro Centre from any and all claims of damage and loss that may arise from the taking and authorized use of videotapes, digital recording films and photographs during the telemedicine / tele health consultation.
(14) Binding: I understand that submitting my request through the TeleMed page on docgautham.com implies that I have read these terms and conditions and that the consent and release expressed by this agreement are binding in any court of law in India.
(15) Perpetuity: I understand that this consent once expressed by submitting a request for Telemedicine / Telehealth consultation through the TeleMed page on docgautham.com will continue in perpetuity unless specifically revoked by me through a registered letter addressed to Doc Gautham’s Neuro Centre or Sakthisri Healthcare Solutions. I also understand that this consent would suffice for me to continue to receive telemedicine / telehealth services at Doc Gautham’s Neuro Centre until revoked in writing.
(16) This agreement is governed by the laws of India and exclusively and irrevocably limited to the sole jurisdiction of Chennai, India. I agree that this agreement shall remain in full force and take effect without change and that participation in the Telemedicine / Telehealth consultation with Doc Gautham’s Neuro Centre is pursuit to the terms of this agreement.
(17) Consent: I have read / have had all the terms and conditions on this page read out to me in my language, and understand the risk and benefits of the telemedicine / telehealth consultation and have had all my questions regarding the procedure explained and I hereby consent to participate in a telemedicine / telehealth consultation with Doc Gautham’s Neuro Centre under the conditions described on this page and confirm the same by submitting my photo identification.