TELEMEDICINE & DATA PRIVACY CONSENT FORM

I understand that in the wake of the present COVID19 crisis, in order to comply with present
guidelines regarding social distancing, my developmental and behavioral pediatrician
(DBP) shall be conducting this consultation and evaluation via video-conferencing
technology, hereby referred to as telemedicine.

I understand that this telemedicine evaluation shall involve

• A discussion of my child’s medical, family, and socioeconomic history, reports from
my child’s school or institution of higher learning, or other information that my
physician may deem pertinent to the evaluation,
• A visual examination of your child that may include, but will not be limited to, a
physical examination, clinical observation of individual behavior, or interaction
between myself, my child, or another member of my family
• A discussion of the findings of the evaluation as well as possible management
options

I understand that this telemedicine evaluation allows my family the benefit of consulting with
our developmental and behavioral pediatrician from the safety of my own home, without the
need to travel to a distant site, or exposing myself or my child unnecessarily in this time of
social distancing amidst the COVID19 crisis.

I understand that there are potential risks and limitations to this telemedicine evaluation
• Certain aspects of the evaluation may be conducted differently than during a face-to-
face consultation, as my child will not be in the same location as the examining
physician;
• A separate face-to-face clinic visit may be deemed necessary to consolidate
information or confirm a diagnosis.
• Interruptions and technical difficulties may occur. I understand that the examining
physician or myself may decide to discontinue the telemedicine consult and resume
at another time if it is felt that the videoconferencing connections are not adequate
for the situation.

I understand that this telemedicine evaluation, including any information provided therein,
shall be part of my child’s medical record, together with any audio or video information
transmitted and received electronically. Reasonable and appropriate efforts have been made
to eliminate any confidentiality risks associated with the telemedicine consultation. I
understand that this telemedicine evaluation is protected under present Philippine laws
regarding data privacy and security; the content therein shall not be shared nor distributed
without written consent by both the examining physician and my family unless required by
order of the court or other pertinent laws, rules and regulations.

I understand that recording of any portion of the telemedicine evaluation (e.g., video
recording, voice recording, photo screenshot) on my end is not allowed. Any medical advice
given to me is applicable specifically to my child/ward and may not be applicable to others.

I understand that all existing laws regarding my access to medical information and copies of
my child’s medical records apply to this telemedicine consultation. I understand that not all
telecommunications are recorded and stored. Dissemination of any patient identifiable
images or information for this telemedicine interaction to researchers or other entities shall
not occur without my consent.

I understand that I may withhold or withdraw consent to this telemedicine consultation at any
time without affecting my right to future care or treatment, nor risking the loss or withdrawal
of any program benefits to which I would otherwise be entitled.

I agree that I have received an adequate explanation of how the telemedicine evaluation
shall take place, and that all my questions have been answered to my satisfaction.

I understand all the information presented above and hereby voluntarily and freely agree to
give my consent for my child to participate in the telemedicine evaluation.

I understand that I may expect the anticipated benefits from the use of telemedicine in my
child’s care, but no results can be guaranteed or assured.

I have also read the Data Privacy Statement and express my consent for the clinic to
collect, record, organize, update or modify, retrieve, consult, use, consolidate, block, erase
or destroy the information pertaining to myself and that of my child.

I hereby affirm my rights pursuant to the provisions of the Republic Act No. 10173 of the
Philippines, Data Privacy Act of 2012 and its corresponding Implementing Rules and
Regulations.

Name of Child/Adolescent ________________________________________

(Last) (First) (Middle)

Name & Signature of Parent/Guardian ________________________________________

(Last) (First) (Middle)

Date Signed (MM-DD-YYYY) ________________________________________