(1) PATIENT CONSENTS

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16-18 Christo Road, Georgetown NSW 2298 | Website: https://teledermatologist.com.au
Phone: 0249 608 277 | Fax: 0249 608 288 | Email: coordinator@teledermatologist.com.au | ABN: 64 242 164 900

If you have any questions please email our coordinators, coordinator@teledermatologist.com.au

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1.1 This document sets out the terms and conditions that apply whenever you make a booking for yourself or a minor under your care to have a consultation with the Practitioner.

By reviewing and ticking to indicate your consent to all of the following items you acknowledge the following terms and conditions apply.

This is a legally binding document that is formed between you, on the one hand, and the Practitioner on the other. No other party, including without limitation, Telehealth Specialists Australia Pty Ltd , will be party to the legally binding agreement.

I confirm that the procedure for conducting the telehealth consultation has been explained to me.

I understand that my participation is completely voluntary and I have the right to refuse to participate and may withdraw my consent and terminate the consultation at any time.

I understand that health professionals are permitted to take notes during the consultation.

I authorise the taking and the storage of images and personal information for medico-legal purposes, diagnosis & further treatment. I authorise the Practitioner to disclose to the following people (or the personal information of a minor) that is made available to or collected by the Practitioner during the course of the consultation: (a) Telehealth Specialists Australia (b) any other person to whom you request the information to be disclosed (c) any other person to whom the Practitioner is required by law to disclose the information

I acknowledge that by conducting a Telehealth appointment I am required to supply photos of the affected area to the coordinator/admin email address to be placed in my file. This may result in photos, including those of my genitalia if affected by skin condition, being viewed by coordinator/admin staff. These photos may also be viewed by staff at MediRecords (the medical software company) in the event that there is corrupted data needing retrieval or patient file modifications.

I understand that telemedicine including teledermatology can have limitations due to lack of physical contact with the patient by the Dermatologist. Although unlikely, this may result in the Dermatologist being unable to provide an accurate diagnosis.

I understand that I can’t make any recording such as audio, video or screenshots of the digital consultation. Doing so would be against the terms of this service, and sharing any recording with a third party would be a violation of the law in all States and Territories of Australia.

I understand that I will be contacted to organise initial and followup appointments and that it is expected that I, or my guardian will be able to reply to messages from Teledermatologist within a reasonable time frame. If I or my guardian is unable to reply, then my next of kin and/or my requesting GP may be contacted about my case.

I confirm that if Teledermatologist has made reasonable attempt to contact me &/or my next of kin about a followup appointment & I or my next of kin have not responded, then Teledermatologist reserves the right to close my case.

The Practitioner agrees to conduct the consultation with you (or minor under your care) and to use reasonable care, skill and diligence in the conduct of that consultation

As consideration for the Practitioner conducting the consultation, you agree to pay to the Practitioner the Practitioner’s fee for the consultation. The amount of that fee is the amount notified to you. If you have made a booking to have (or for a minor under your care and supervision to have) a consultation with the Practitioner but you (or the minor) do not attend at the relevant time and place for the consultation, then you must pay to the Practitioner a cancellation fee. The Practitioner may waive the cancellation fee at her or his discretion. The amount of the cancellation fee is the amount notified to you.

The Practitioner is providing the medical consult to you. Telehealth Specialists Australia Pty Ltd provides a telehealth service platform, Teledermatologist, co-ordinating your consultation with the doctor. In utilizing this service you agree to indemnify Telehealth Specialists Australia Pty Ltd for any outcomes from your consultation(s) with the Practitioner

TSA and your treating doctor are not responsible for any loss, transmission, corruption or exploitation of these photos in case it is leaked or hacked via no fault of TSA’s via the MediRecords company. You reneged all legal claims and compensation in case of these events when TSA is not in direct fault.

必須

1.2 Not Essential:

I authorise the use of these unidentified images for educational purposes ensuring my confidentiality

I authorise the publication of unidentified diagnostic images in medical papers ensuring my confidentiality.

I authorise the sharing of my contact details for marketing purposes

1.3 The patient is aware of the following: *

I understand the Dermatologist is a private practitioner and authorise Teledermatologist to debit the fee communicated to me on behalf of the Dermatologist. This fee has been communicated to me via phone, email or the Teledermatologist website and I acknowledge that this fee is payable prior to the consultation.

必須

1.4 Patient full name *

1.5 Patient, guardian or carers email address *

1.6 Today's Date *

YYYY

1.7 Acceptance *

By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.

必須

1.8 Acceptance Initials *

1.9 Witness name

1.10 Date (witness)

YYYY

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