First Response Emergency Services – Consent Form

I understand that my health care provider (Royal Bahrain Hospital) is providing me with a FIRST RESPONSE SERVICE Consultation. This means that I and/or my healthcare provider or designee will, through interactive audio/video connection, be able to consult with the clinician (assigned by the Emergency Services Dept., Royal Bahrain Hospital) about my condition.

I understand there are potential risks with this technology:

1. The video connection may not work or that it may stop working during the consultation.

2. The video picture or information transmitted may not be clear enough to be useful for the consultation.

3. I may be required to go to the location of the consulting physician if it is felt that the information obtained via telemedicine was not sufficient to make a diagnosis.

I also understand other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained.

I understand that a limited physical examination will take place during the videoconference and that it cannot replace a full medical examination done physically at the medical centre/clinic. I have the right to ask my healthcare provider to discontinue the conference at any time.

I authorize the release of any relevant medical information about me to the consulting health care provider, any staff the consulting health care provider supervises, third party payers and other healthcare providers who may need this information for continuing care purposes.

I also understand that the responsibility of the consulting provider regarding my health care will terminate upon conclusion of the teleconference.

I hereby release Royal Bahrain Hospital, its personnel and any other person participating in my care from any and all liability which may arise from the taking and authorized use of such Video/E Consultation, Videotapes, Digital recording films and Photographs. I have read this document and understand the risk of the video consultation.

I hereby consent to participate in a Video/E consultation under the conditions described in this document.