TELEMEDICINE CONSENT FORM

Marr Antoniette D. Boncan, MD, MBAH

Master of Business Administration in Health
Fellow, Philippine Obstetrical & Gynecological Society
Fellow, Philippine Society of Fetal & Maternal Medicine
Fellow, Philippine Society of Ultrasound in Obstetrics and Gynecology

Name: Marielle Mendiola Age: _________

Nature of Teleconsult: OB __X Gyn _____
Purpose of Teleconsult: Erythroblastosis fetalis
Others: ____________________________
The PURPOSE of this form is to obtain your consent to participate in a
telemedicine consultation in which the following may be
discussed/shared/shown:
1.) Details of your medical history, previous and present laboratory exams, x-
rays, and other imaging modalities related to your condition
2.) Video and audio are used to conduct the teleconsultation
3.) All information stored in your physician’s gadgets (laptop, cellphone,
tablet) are used only as reference and hence shall be deleted after same results
are written on your clinic chart
4.) Reasonable and appropriate safeguards have been made to eliminate any
conflict in confidentiality associated with telemedicine consultation
5.) You agree that teleconsultation is utilized to avoid the risk of frequent
face-to-face follow-ups, and that the appropriate reasons for doing so was
well explained, especially during the COVID-19 pandemic.
I, _Marielle Mendiola_____, therefore agree to participate in a telemedicine
consultation with Dr. Boncan.
DATE: _8 August 2022_________
TIME STARTED: 845 to 9 pm______________
E- SIGNATURE: