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Informed Consent for Telemedicine

I hereby consent to engaging in telemedicine and online services with HSC Medical Center. Telemedicine involved in the use of electronic communication to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers at HSC Medical Center may include primary care practitioners, specialists and/or subspecialists.

I understand that telemedicine includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical information, both orally and visually, to health care practitioners. The information may be used for diagnosis, therapy, follow-up and or education, and may include any of the following:

  1. Patient medical reports
  2. Medical images
  3. Live two-way audio and video
  4. Output data from medical devices and sound and video files.

Electronic systems used will incorporate network and software security protocols to protect the confidentially of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Potential Risks

The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my treatment is confidential. As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

  1. In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
  2. Delays in medical evaluation and treatment could occur due to deficiencies or failure of the equipment;
  3. In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;


I have no other pre-existing medical conditions that have not already been disclosed here. I understand that this visit/encounter does not and should not replace a traditional doctor's office visit; and therefore, I am proceeding with this tele-consultation at my own risk and understanding. I also understand that if I experience any medical emergency, I should contact local emergency response or a doctor immediately. I certify that the information provided in this medical form is true and accurate to the best of my ability. I also understand that omitting medical information or misinforming HSC Medical Center may result in an inaccurate diagnosis and treatment.

Informed Consent for Third Party Disclosure

HSC Medical Center reserves the rights to disclose Patients' information to third party received for services offered by HSC Medical Center:

The personal data obtained from the Patient/Recipient will be further processed or/and disclosed to third parties as required or permitted by law for the home delivery of medication, verification, labeling and packing services, global logistics delivery, customs and immigration and payment collection and settlement services or any other entity as required by the governing law of the country. For the delivery and/or payment service, the third party shall communicate to the Recipient, alerting the Recipient to receive the Order.

HSC Medical Center abides by the Section 7 of Personal Data Protection Act (PDPA) 2010 that includes the purpose for which the Patient's personal data and sensitive personal data is collected/processed and classes of third-party to whom HSC Medical Center will/may disclose the Patient's personal data. I/we hereby give consent to HSC Medical Center to collect or process the Patient's personal data and sensitive data (including health information and religious beliefs) in accordance with the written notice. I hereby undertake that the information provided here is true and correct.