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Manipal Hospital Goa
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Manipal Hospital Goa
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Consent and Declaration
I, the undersigned, declare that the above information provided by me are true to the best of my knowledge and hereby provide my consent to the Manipal Hospital to provide Medical Care, Treatment, Conduct Investigations and Diagnostic Procedures necessary for the above mentioned individual by Medical Staff at Manipal Hospital. I, also understand that Manipal Hospital will not be responsible for any loss, damage or theft of any Personal Property/Belongings of Me/Patient/Visitors within the Hospital Premises. Including Patients rooms and Parking area. I agree to follow all the rules and regulations of Hospital and clear all the expenses incurred for My/Patient treatment on time as per the Terms and Conditions of Manipal Hospital,
I would like to receive Self/Patient reports by Email
I would like to receive Hospital Info Alerts reports by Email
If consent provided on behalf of the patient.
I hereby give my consent and authorize Manipal Hospitals to process, store,use,disclose my personal or sensitive information/data collected as per Manipal Privacy Policy
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The benefits of Prime Access OPS are as below:
- Minimal Waiting Time for Consultations.
- Exclusive Waiting Area
- Personal Attention.
- Fast tracked Services.
Refund Policy
1) Up to 4 hrs of appointment time:
Rescheduling of doctor appointment can be done within a week from the date of appointment as per doctor / slot availability.
Cancellation can be done with full refund of the payment.
2) Up to 2 hrs of appointment time:
Rescheduling of doctor appointment can be done within a week from the date of appointment as per doctor / slot availability.
Cancellation of appointment and refund with a cancellation charge of Rs.100/-.
3) Less than 2 hrs of appointment time:
Rescheduling / cancellation of appointment cannot be done, payment non-refundable in this case. However, Units can have the discretion to refund / reschedule in case of exigencies.
Please note : While making the payment online, above mentioned payment terms and conditions should be agreed upon by customers, by clicking in a box ( I agree) and then proceed for payment.
PATIENT CONSENT FOR TELEMEDICINE / TELECONSULTATION
Telemedicine involves the use of electronic communications to enable Hospitals/health care centres to provide healthcare services at different locations through exchange of information and for the purpose of improving patient care. I, confirm that I have received the necessary information to sign this form and I agree to take part in a live telemedicine/teleconsultation session with Manipal Hospitals.
I understand that:
- Interactive audio/video connection, electronic information and communication technologies shall be used for providing me with a telemedicine/teleconsultation.
- In case the information obtained via teleconsultation is not sufficient to make a diagnosis, I may be required to go to Manipal Hospitals for in-person consultation.
- Though the telemedicine/teleconsultation is private, other individuals, medical and non-medical, may be present to facilitate the consultation and that they will take reasonable steps to maintain confidentiality of the information obtained.
- A limited visual examination will take place during the telemedicine/teleconsultation and that it cannot replace a full medical examination done physically at Manipal Hospitals.
- I have the right to withhold or withdraw my consent to the use of telemedicine/teleconsultation in the course of my care at any time, without affecting my right to future care or treatment. I may also revoke my consent orally or in writing at any time.
- I may be prescribed medicines for treatment or/and diagnostic tests to further evaluate my health condition. All prescription will be sent to my registered email/phone no. Manipal Hospitals will keep a record of the consultation & prescription in my medical record.
- The telemedicine/teleconsultation services are not in any way intended to be used in case of an emergency.
- There can be potential risks with this technology e.g information transmitted may not be sufficient to allow for appropriate medical decision, the video /audio may disconnect/stop in-between, security protocols could fail causing a breach of privacy of personal medical information.
- Any relevant medical information about me including details of my medical history, examinations, x-rays, tests, photographs or other images may be transmitted /shared by Manipal Hospitals with their staff, specialist, business partners for the purpose of record, communications, feedback, enquires, follow ups, analysis etc.
- Manipal Hospitals responsibility shall terminate upon conclusion of this teleconference.
- I hereby consent that in consideration for the telemedicine / teleconsultation services rendered to me, I agree to pay the relevant charges.
- I hereby release Manipal Hospitals, its personnel and any other person participating in my care from any and all liability which may arise from authorized use of such Video / E-Consultation, Videotapes, Digital recording films and Photographs. I have read this document and understand the risk of the telemedicine / teleconsultation.
- I hereby consent to participate in a telemedicine / teleconsultation under the terms & conditions described in this document.
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