Informed Consent
This document serves a confirmation that you have read, understood and agree to proceed with the Online Consultation with Dr. Mabelle Colayco for your dermatological concern.

Kindly review the document before affixing your name to signify your consent.

Thank you for your cooperation.

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Email *
Teledermatology Guidelines
All data and photos are to be kept strictly confidential between doctor and patient.
All communication will be done strictly through
     - Email for all details of the consultation
     - Phone messages only for reminders
Informed consent should be accomplished before the start of the online consultation.
The consultation fee should be paid before the start of the online consultation.
Patients need to answer the Online Consultation Questionnaire.
Then you may choose proceed via:
     - Email
     - Video consultation

I have read, understood and agree to the TELEDERMATOLOGY GUIDELINES presented by Dr. Mabelle Colayco. *
I agree to answer the Online Consultation Questionnaire. *
I would like to proceed with the Online Consultation thru: *
If you chose Video Consultation, please choose the platform you wish to use:
Clear selection
I agree that the digital prescription and/or laboratory requests and/or invoice will be sent to my email address. *
DATA PRIVACY AND INFORMED CONSENT
Your patient data will be stored in our online database.

Email messages will be deleted within 90 days of receipt of initial patient email.

No part of the Video Consultation may be recorded.

Only patients with signed Informed Consent can be evaluated.

Please write your name if you consent to proceed with the Online Consultation. *
Surname, Given name, Middle initial
Please write the date when you signed this consent form. *
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