Consent Form

This document is to be read, understood, and approved, either for oneself, or for the client, by a person who is not a minor (below 18 years of age, at the time of providing consent) before availing any NICE Teleconsultation or Medical Tourism Service. In case this service is to be availed by a minor, then his/ her caregiver/ parent (above 18 years of age at the time of providing consent), will fulfill this responsibility.

As the client/ caregiver interested in availing this service, I have taken cognisance of the following:

About Telemedicine

Telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or health education.

NICE Teleconsultation Services deliver the concept of telemedicine in the fields of mental health and rehabilitation, for various age groups.

About Medical Tourism

Medical Tourism involves traveling to another location or country to receive medical treatment, often combining care with recuperation or travel. It includes planned medical procedures, wellness programs, and specialized consultations in reputed facilities.

NICE Medical Tourism Services support clients by facilitating medical procedures with seamless coordination between healthcare providers, local logistics, and support staff.

Possible Risks

I understand that as with any medical procedure, there are potential risks associated with the use of telemedicine and medical tourism, and hence, NICE services. These risks include, but may not be limited to:

In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision-making.
Delays in medical evaluation and treatment could occur due to deficiencies or failures in technology or coordination.
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
No video recording on either side.
Security of videoconference/internet is dependent on the service provider’s policy and is beyond the scope of the consultant.
Clinical judgment is based on limited assessment (i.e., to the extent possible on video call), including a partial virtual physical examination (VPE).
Not to be used for emergencies.
Need for in-person consultations whenever video call is not possible or feasible.
For Medical Tourism: Possible travel delays, logistical issues, or last-minute schedule changes due to medical or legal conditions.

Consultation between Client and Healthcare Provider, through the Caregiver

I understand that for the purpose of this document, “Caregiver” could be a family member, or any person authorized by the client to represent the client. In this there could be two possible settings:

Client is present with the Caregiver during the consultation.
Client is not present with the Caregiver. This proxy appointment may be the case in the following:
- i). Client is a minor (aged 18 or less) or the client is incapacitated, for example, in medical conditions like dementia or physical disability etc. The caregiver is deemed to be authorized to consult on behalf of the client.
- ii). Caregiver has a formal authorization or a verified document establishing his relationship with the patient and/or has been verified by the patient in a previous in-person consult (explicit consult).

In case a proxy appointment is sought by the caregiver, the Registered Medical Practitioner (RMP) may choose to communicate best possible guidance on the client’s likely clinical state, instead of prescribing medication

Confidentiality and Recording

I understand that video/audio consultation is strictly confidential. I agree to use a secure line/connection for these consultations, in a relatively quiet and private space. I understand that my consultant will not audio or video record the session (either on mobile, using an app or online) and will not share the proceedings of this consultation with any other individual or agency.

However, with my consent, my consultant/ healthcare provider could use it to have their work supervised or for training of professionals. Apart from this, the details of the consultation would be shared only with a court of law, if mandated.

Notes of the teleconsultation will be maintained by my consultant/ healthcare provider and stored in a safe location. I understand that these session notes can be made available to me, in the standard session record format, on my explicit request.

I also undertake that the proceedings of these consultations or Medical Tourism interactions are not to be recorded, shared, or disseminated by me or my relatives/contacts to any third person or through social media.

However, despite safety measures taken, there are chances for breach in security in technology. In such instances, both client and consultant will not hold the other responsible for the breach.

I have read and understood the information provided above regarding NICE Teleconsultation and Medical Tourism Services, I hereby give my informed consent for the use of these services for me.

I confirm that I am at least 18 years of age or above, at the time of providing this consent.

I understand that my consent expressed online would suffice for me to receive teleconsultation and/or medical tourism services.

I have read and understood NICE’s Terms & Conditions, Refund & Reschedule, Cancellation Policy, Disclaimer, and Privacy Policy. I agree to receive emails and push notifications about my consultation or medical tourism arrangements, including the healthcare provider’s name and consultation time.