CONSENT TO PARTICIPATE IN A TELEMEDICINE DEVELOPMENTAL EVALUATION

Due to the COVID-19 crisis, safety guidelines set by the Department of Health are still
advised to be followed even after the enhanced community quarantine has been lifted. For
everyone’s safety, the temporary implementation of a remote medical consultation
(“Telemedicine”) will be done through online video conferencing by my developmental
pediatrician Dr. Ma. Theresa De Castro.

I understand that a telemedicine version of a developmental evaluation will include a

medical interview of the patient’s history, visual examination, observation of the patient’s
interactions, performance of certain tasks applicable to patient, discussion of findings, and
discussion of intervention options.

I understand that a tele medical version of my evaluation will slightly differ from a visit
to my doctor’s clinic because some aspects of the evaluation cannot be done online, such as the
use of specific evaluation materials.

I understand that a telemedicine evaluation may have potential issues, such as

interruptions due to internet connectivity and unauthorized access. I understand that I as well as
my doctor can decide to discontinue the consultation if there are technical difficulties and
reschedule accordingly.

I understand that my doctor will keep all the information obtained during this
telemedicine consultation confidential and will be treated as medical record.

I understand that I am not allowed to record any portion of the telemedicine evaluation
(e.g. video recording, voice recording, photos, screenshots).

I hereby voluntarily and freely give my consent for me and the child to participate in the
telemedicine evaluation.

Name of Child: _ASHRIELLE WYNETH E.

MALABANAN_

Name and Signature of Parent/Guardian: ____________________________________

Date Signed (Month-Day-Year): ____________________________________