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MediCard Philippines, Inc.

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Head Office: 8 Floor, The World Centre Building
330 Sen. Gil Puyat Avenue, Makati City 1200
Trunkline: 88-4-9999 Fax Nos.: 810-3855; 848-6454
Email: inquiry@medicardphils.com
Website: www.medicardphils.com

TELEMEDICINE CONSENT

TELEMEDICINE will conduct the consultation via audio or video conference. When availing
yourself of the services of TELEMEDICINE, you agree that we will not be conducting physical
examination or certain vital signs reading. Hence, our doctor will primarily rely on the information that
you will provide us thru audio or video consultation. MediCard has no control over audio and video
recordings during consultation. To protect your privacy, you may advise your doctor that you refuse to
record any images, audio, or video materials during your consultation.

______________________________________ ______________________
Signed over Printed Name of Patient Date and Time Signed

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MediCard Philippines, Inc.


th
Head Office: 8 Floor, The World Centre Building
330 Sen. Gil Puyat Avenue, Makati City 1200
Trunkline: 88-4-9999 Fax Nos.: 810-3855; 848-6454
Email: inquiry@medicardphils.com
Website: www.medicardphils.com

TELEMEDICINE CONSENT

TELEMEDICINE will conduct the consultation via audio or video conference. When availing
yourself of the services of TELEMEDICINE, you agree that we will not be conducting physical
examination or certain vital signs reading. Hence, our doctor will primarily rely on the information that
you will provide us thru audio or video consultation. MediCard has no control over audio and video
recordings during consultation. To protect your privacy, you may advise your doctor that you refuse to
record any images, audio, or video materials during your consultation.

______________________________________ ______________________
Signed over Printed Name of Patient Date and Time Signed

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