INFORMED CONSENT TELECONSULTATION

INTRODUCTION

Telemedicine involves the use of telecommunications technology and electronic means to enable our communication with you, reviewing your medical information for purposes of diagnosis, therapy, monitoring, and education. Electronic communication means the use of telecommunications equipment including, at a minimum, audio and / or video equipment that enables our two-way interactive communication in real time.

I understand that, as with any medical procedure, there are expected benefits and potential risks associated with the use of Telemedicine that I need to know about.

Expected benefits include the following:

Improved access to care by allowing a patient to remain at their location while the physician provides medical care from a distant location. Patients can be diagnosed and treated earlier, which can contribute to better results and less expensive treatments.

Obtain the care of a remote specialist.

Obtain your medical formulation, exam request and medical certificates in digital format valid for immediate use.

Continuous monitoring of your health condition in the comfort of your home.

Reduces travel costs and risks.

Potential risks include, but are not limited to:

• Despite reasonable protection efforts, the transmission of medical information could be altered or distorted by technical failures that could cause delays in the evaluation; the transmission of medical information could be interrupted by an unauthorized person; and / or the electronic storage of medical information could be accessed by unauthorized persons.

• Telemedicine-based services may not be as comprehensive as face-to-face services. I understand that if the doctor defines that I must be treated personally, I must follow the instructions of the healthcare personnel to obtain the consultation.

• In rare cases, the information transmitted may not be sufficient (eg poor image resolution) to allow appropriate decision-making by the physician.

• In rare cases, lack of access to complete and / or accurate medical information or records may result in adverse drug reactions, allergic reactions, or other inconsistencies.

By continuing with the consultation you virtually accept this form, I understand the following:

1. I understand that I can expect benefits from the use of Telemedicine in my medical care, but that the results, as in regular medical care, cannot be guaranteed.

2. I understand that I have the right to inspect all information obtained and recorded in the course of a Telemedicine interaction and may receive copies of this information.

3. I understand that alternative health / medical care methods may be available including face-to-face interaction and that I can choose another alternative at any time.

4. I understand that I have the right to deny or withdraw my consent to the use of Telemedicine in the course of care, without affecting my right to receive care or treatment in the future.

5. The laws that protect the confidentiality of my medical information also apply to telemedicine. However, due to regulations, the doctor or health personnel who attends me in case of knowing information, on the occasion of the consultation, about intrafamily violence, abuse or mistreatment, among others, has the duty to inform the competent authorities.

6. I understand that the rules that protect the Reserve, confidentiality, custody, security and treatment of my personal data and health information, apply to telemedicine and that no information, obtained in the use of telemedicine, which identifies me, will be disclosed to third parties not authorized by the regulations without my authorization.

7. The presence of technical personnel may be necessary during the consultation in order to support remote transmission.

Patient Consent for the Use of Telemedicine

Digitally registered through the electronic platform, attesting that my data is correct and real. I declare that I have been informed by the medical personnel, on the occasion of the sending of the information of my medical history and in general of my state of health, authorized so that through the procedure called TELEMEDICINE (synchronous / asynchronous), the doctor Dr. Buendia Saavedra Luis Alberto specialist in orthopedics; analyze my clinical case; I fully understand that it is a medical assessment modality, which I ACCEPT as part of the medical diagnosis or treatment received.

I have read and understand the information provided above about Telemedicine. I hereby give my informed consent for the use of Telemedicine in my medical health care by continuing this medical care.

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