CONSENT FOR E-CONSULTATION

I hereby agree to the following points

1. Purpose: To obtain your consent to participate in a teleconsultation in connection with the following service(s) and/or procedure(s)
   • Patient Health Records
   • Medical Images
   • Live audio and video interaction
2. Electronic systems: Electronic systems used will incorporate network and software security protocols to protect confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional and unintentional corruption in accordance to UAE Laws and Regulations.
3. Nature of Teleconsultation: During the teleconsultation
   • Details of your medical history, examinations, x-rays and tests may be discussed with other healthcare professionals with interactive videos, audio and telecommunication technology.
   • A physical examination may need to take place.
   • A non-medical technical person may be present in the teleconsultation studio to aid in the video transmission.
   • Audio and/or photo recordings may be taken for accurate diagnosis, treatment and quality control.
   • Video call will be recorded and kept in patients’ health record.
4. Medical Information and Records: All existing federal laws and local regulations/policies/guidelines regarding access to medical information and copies of your Health Records apply to this teleconsultation. Dissemination of any patient identifiable images or information for this teleconsulation interaction to other entities will not take place without your consent.
5. Medical Information and Records: All existing federal laws and local regulations/policies/guidelines regarding access to medical information and copies of your Health Records apply to this teleconsultation. Dissemination of any patient identifiable images or information for this teleconsulation interaction to other entities will not take place without your consent.
6. Rights: You may withhold or withdraw consent to teleconsultation at any time without affecting your right to future care or treatment.
7. Disputes: You agree that any disputes that arise from the teleconsultation will be resolved as per UAE laws and regulations and will be raised with the teleconsultation provider in the first instance.
8. Expected Benefits:
   • Improves access to medical care by enabling a patient to remain in their home, office (or a remote site) while your DHA licensed dentist obtains test results and consults with other DHA licensed dentist at distant/ other sites.
   • More efficient medical evaluation and management.
   • Access to expertise from distant specialist in the UAE or experts outside.
9. Possible Risks: As with any medical procedures there are potential risks associated with the use of Teleconsultation, which may include, but not limited to the following:
   • Information transmission may not be sufficient (e.g. poor resolution of images) to allow appropriate decision making by the consulted dentist.
   • Delays in medical evaluation and treatment could occur due to deficiencies or failure of equipment.
   • In rare instances, security protocol could fail causing a breach of privacy of personal medical information.
   • In rare cases, a lack of access to complete health records may result in adverse drug interactions, allergic reactions, or other judgement errors.
10. Expected Benefits and Possible Risks: You have been advised of all the risks, consequences and benefits of teleconsultation. Your treating dentist has discussed with you the information provided in a language you can understand. You have had the opportunity to ask questions about the information presented in this form and about the teleconsultation. All your questions have been answered and you understand the written information provided above.

I agree to participate in the teleconsultation for the service(s)/procedure(s) mentioned above.