Telemedicine Consent Form

Introduction: Telemedicine involves the use of electronic communications to enable health care 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 education, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

• Improved access to medical care by enabling a patient to remain in his/her own home of a remote location while the physician obtains test results and consults from healthcare practitioners at distant/other sites
• More efficient medical evaluation and management.
• Obtaining expertise of a distant specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine. 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 by the physician and consultant(s);
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• 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;

By agreeing to undertake a Telemedicine consultation with Longevity Wellness Pvt Ltd, I understand the following:

1. . I hereby authorise Longevity Labs Pvt. Ltd to use the tele-health practice platform for telecommunication for evaluating, testing and diagnosing my health.
2. I understand that technical difficulties may occur before or during the tele-health sessions and my appointment cannot be started or ended as intended.
3. I accept that the professionals of Longevity Labs Pvt. Ltd can contact me for interactive sessions with a video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
4. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.
5. . I agree that my medical records on tele-health can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.
6. . I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

Consent To The Use of Telemedicine

I have read and understand the information provided above regarding telemedicine, and all of my questions have been answered to my satisfaction.

I hereby give my informed consent for the use of telemedicine in my medical care.

1. I hereby authorise Dr. Ashwani Garg from Longevity Wellness Pvt Ltd, and those whom Dr. Ashwini Garg or Longevity Wellness Pvt Ltd may designate as associate or assistants, to translate and execute his instructions, to evaluate the reports and medical history for dispensing a personalised treatment plan.
2. Among many other services offered by Longevity Wellness Pvt Ltd, I have understood that Longevity Wellness Pvt Ltd offers tele-consultations for Functional Medicine. I have clearly undertook that Functional Medicine is a different approach from the existing health care model.
3. I have understood that the disease under treatment is for a chronic condition and that Longevity Wellness Pvt Ltd, does not handle acute health conditions.I will need a Primary Care Physician/Family doctor to attend to any of my medical emergencies while on treatment with Functional Medicine Clinic.
4. Following has been fully explained to me and I have understood the same:
   • Dr Ashwani Garg or any of the assigned physicians or consultants by Longevity Labs Pvt Ltd, may use complementary, integrated, non-traditional, holistic/ Functional Medicine methods during treatment.
   • The nature and duration of the treatment, tentatively and without break.
   • Expected outcome of the treatment (subject to body response).
   • The kinds and possibilities of detox and die-off reactions in the treatment.
   • I understand that if I experience any such reactions, I am responsible for following up with my physician at my expense. Occurrence of complication carries no indemnity.
   • I have also understood that my voluntary or unavoidable discontinuation of the treatment at any stage before the completion of the duration may not give me any or proportionate relief.
   • This possible alternative method of treatment has been discussed and I have chosen this option and accepted the present recommendation as the treatment of choice of my own free will, without any inducement or undue influence of any kind whatsoever.
   • My present consultants shall describe and decide upon any second opinion or expert opinion, referral, or to simultaneously take, if required at any stage.
5. This consent of mine shall hold and bind me to any change in prescriptions, or modification of treatment, at any stage as per the clinical judgment of my present consultants and would ratify the same without any fresh consent form being filled in, unless a new disease is discovered or impacted.
6. I understand that any side effects include, but are not limited to, failing to properly administer the medication/supplement, failing to observe side effects, failing to assess and/or recognise an adverse reaction, failing to assess and/or recognize a medical emergency, and failing to recognise the need to summon emergency medical services.
7. I do hereby fully release or discharge Longevity Wellness Pvt Ltd, Dr. Ashwani Garg and any of the associates, consultants or assistants of Longevity Wellness Pvt Ltd from any and all claims from injuries, damages and losses I may have, or accrue, and arising out of, connected with, incidental to, or in any way associated with the treatment.

Having understood all of above, and after having raised my own questions, concerns, doubts, clarifications, I am ready and willing to undertake the treatment and give my consent for starting the treatment after satisfactory consultation, which I am aware of, depends on my strict compliance and follow up of the clinical advice given from time to time.