AUTHORIZATION AND CONSENT TO PARTICIPATE IN

TELEMEDICINE CONSULTATION

I hereby consent and authorize the following Allergy and Immunology Specialist:
Beatrice S. Vicente,_MD__________Beatrice S. Vicente,MD_____________ (the “Specialist”) to
provide me with a telemedicine consultation (“teleconsultation”) for my medical
concerns/needs as I am unable to seek direct or face-to-face medical care due to the strict
home quarantine regulations presently imposed by the Philippine government during this
COVID – 19 pandemic.

I further accept and confirm the following rules and regulations regarding my teleconsultation
with the Specialist:

1) Setting-up of a teleconsultation:

a) Contact the following person (the “secretary”): __________________, Contact Nos.

_____________ to set an appointment with the Specialist based on the following
schedule of clinic hours:
______________________________________________________________.
b) The patient shall be given a slot for his/her teleconsultation with the Specialist for a
maximum period of Twenty (20) minutes.
c) The patient shall download the ZOOM app (free of charge) on his/her chosen
devise, i.e. computers, tablets or mobile phones which will be his/her medium of
communication with the Specialist during the teleconsultation.
d) The patient shall be given a teleconsultation ID number and password for his/her
scheduled teleconsultation.

2) Nature of the teleconsultation. During the teleconsultation:

a) Details of the patient’s medical history, examinations, x-rays, and laboratory tests
shall be discussed by the patient and/or his/her guardian with the Specialist and/or
other health professionals, using interactive video, audio and telecommunications
technology.
b) Since there will be no actual or physical examination of the patient by the Specialist
due to the inability of physical access to each other, the Specialist shall have the
right to request the patient and/or his/her guardian to send a video or clear pictures
of the patient’s symptoms to the specialist email address
beatricevicente@yahoo.com______________ prior to or during the
teleconsultation.
c) Non-medical technical personnel may be present in the telemedicine site to aid in
the video transmission of the teleconsultation between the patient and the
Specialist.
d) The patient shall not record any video, audio and/or digital photographs for the
duration of the teleconsultation. The ZOOM app can easily detect a video or audio
 recording. In case such recording is done, the teleconsultation shall be rendered
ineffective and shall not, at any instance, bind the Specialist.

3) Prescription of Medicines. The Specialist shall prescribe the medicines needed by the
patient based on the teleconsultation. After the teleconsultation, the prescription shall
be sent by the Specialist or the secretary to the patient via Viber text or picture.

4) The Patient’s Medical information and Records: All existing laws regarding medical
information and copies of the patient’s medical records apply to the teleconsultation. The
dissemination of any patient-identifiable images or information from the teleconsultation
to researchers or other entities shall not be done by the Specialist without the patient’s
consent, unless authorized under existing laws such as but not limited to the Philippine
Data Privacy Act.

5) Confidentiality. Reasonable and appropriate efforts have been made by the Specialist to
eliminate any confidentiality risks associated with the teleconsultation. The existing
confidentiality protection under Philippine laws shall apply to the information disclosed
by the patient during the teleconsultation.

6) Risks and Consequences. The teleconsultation is an alternative measure to routine

medical office visits using interactive video technology which will allow the patient to
communicate with the Specialist at a distance. The patient may find it difficult or
uncomfortable to communicate using video images as the use of video technology to
deliver healthcare and educational services is a new method. However, the
teleconsultation may not be considered as equivalent to direct patient-to-physician
contact (where the patient’s actual condition may be examined by the Specialist). The
Specialist shall have the prerogative to recommend that the patient visit the nearest
hospital for further evaluation after the teleconsultation.

7) The Patient’s Prerogative. The patient may suspend or end the teleconsultation with the
Specialist at any time during his/her slot, without affecting his/her right of future care or
treatment. The patient may likewise opt to consult with another doctor in person, should
the Specialist deem that a face-to-face consultation between the patient and a medical
professional is necessary.

8) Medical Fee. The fee of P800 (eight hundred pesos only) for a teleconsultation of Twenty
(20) minutes shall be paid by the patient to the Specialist prior to his/her slot. The
payment shall be made by depositing to BPI account 0766088887 or by remitting
online/bank transfer. Prior to or at the start of the teleconsultation, the patient and/or
his/her guardian shall send a copy of the deposit slip or a picture of the online
remittance/bank transfer by email to the Specialist or the secretary.

I have been advised of all the potential risks, consequences and benefits of teleconsultations
and I have read and understood the information provided above which was explained to me by
the Specialist in the language I am familiar with. I have been given the opportunity to ask
questions about the foregoing information and all my questions have been properly answered.

I hereby execute this Form willingly and voluntarily prior to or at the start of the
teleconsultation.

Name of Patient: JEAH NICOLE EUGENIO Age: 12

Signature: Annaline Eugenio_ Date : February 12, 2022

Patient or Guardian

If signed by a person other than the patient, please provide the following information:

Name: Annaline Eugenio Relationship to the patient: Mother