Patient Consent Form for Online Consultation With Doctor
DR G D MEMORIAL HOMEOPATHIC CLINIC AND WELLNESS CENTRE
CONSENT FORM FOR ONLINE CONSULTATION
I hereby agree and consent to the following:
I authorize the Doctors introduced by DR G D MEMORIAL HOMEOPATHIC CLINIC AND WELLNESS CENTRE to assess my medical history and to provide healthcare services on ???as is??? and ???as available??? basis, including PRESCRIPTION OF HOMEOPATHIC MEDICINES WILL NOT BE GIVEN TO PATIENT OR THEIR RELATIVES. as deemed necessary. I am aware that healthcare services will be provided through telephonic or Internet consultation with the Doctors and that there will be no physical examination. I agree that the diagnosis based on telephonic consultation will be at a pre-primary level and that I will visit another doctor either as directed by the Doctor undertaking the telephonic consultation or a doctor of my choice for further treatment. During the course of the treatment I will disclose sensitive personal information (???SPI???) which will include without limitation (i) physical, physiological and mental health condition, symptoms and history; (ii) medical test results in connection with the aforesaid; (iii) medical records and history; and (iv) biometric information to the CLINIC , which the Company may store, use and disclose to the Doctors solely for the purposes of treatment. The HOMEOPATHIC CENTRE not publish and disclose the SPI to any third person or body corporate without my express written consent, except when mandated by law. I may review the medical history and other related records provided by me to the CENTRE and request the CENTRE to correct or amend any inaccurate or deficient information. The HOMEOPATHIC CENTRE HAS will not be responsible for the authenticity of the SPI provided by me to the Company. I agree that the HOMEOPATHIC CENTRE liability will only be limited to the professional services rendered by it and that the HOMEOPATHIC CENTRE does not make any guarantee, representations or endorsements or implied or express warranties with respect to the services provided by any Doctor engaged by it. I consent and agree to submit myself to the exclusive jurisdiction of the competent court at BHOPAL only.
Terms and Conditions
Please read these terms and conditions carefully before availing the HEALTH CARE services. By subscribing/ using the services, you hereby acknowledge that you are familiar with these terms and conditions and any change or modifications that may occur from time to time.
The following information shall be referred to as Personal Information:
Password to the Company???s website; Name, date of birth, postal address, e-mail and telephone number; Physical health condition and medical history; mental health condition; Family???s medical condition; and Biometric information.
The HOMEOPATHIC CENTRE does not provide emergency medical services. If you are having a medical emergency, call your local emergency contact number. The CENTRE may provide you with the phone numbers and addresses of medical facilities and emergency services, but using those services is at your own risk. The CENTRE is not responsible for the accuracy of this information or for any delay in seeking hands-on emergency treatment.
By using the services of the HOMEOPATHIC CENTRE you agree that you have understood all of these terms and conditions, and consent to receiving phone-based or internet-based consultation and information from the Company. The HOMEOPATHIC CENTRE ehomeovision reserves the right to make changes to these terms and conditions.
The terms and conditions and the services will be governed as per the applicable laws of India and the courts of Madhya Pradesh only will have exclusive jurisdiction over all or any matters arising out of or relating to these terms and conditions or the services.
[11/1, 9:07 PM] Trendsetter: ehomeovision.com/start your Consultation
The Procedure To Start Is Very Simple
Step 1 : Fill the case taking form and subscribe our YouTube channel https://www.youtube.com/c/ehomeovisiondrrajeshmanghnaniofficial
Step 2 : Make the payment via Paytm mobile app /Google pay/Phone pay/BHIM UPI on 9893064165 for Indian nationals only. For International clients bank details will be shared via email. firstname.lastname@example.org
Step 3 : After the completion of the payment, online call via What???s app video call will be scheduled with the doctor for detailed discussion regarding the patient condition and queries.
Step 4 : The medicine is mailed to you though Premium Courier service at your address within 7 working days.
Please Note : Any kind of Physical Examination will not be done during the Online calls, please share all the previous relevant reports , photographs (in case of a skin disease) for which treatment is sought along with the case form only???..
- Full Name:???????????????????????????Date : ?????????
- Height: ??????
- Address with phone no:
- Marital status: Married/ single, duration
- Presenting complaints: please mention in the following pattern (retrospective way with year of occurrence of symptoms) of all the physical problems / diseases/ diagnosis currently patient is suffering from:
??? Since when the complaints started?
??? How has been the progress of complaints ( sequence of appearing of symptoms along with factors which increase or decrease the complaints)
- Associated complaints (Any symptom which accompany the main symptom/ other symptoms or disease other than main complaints)
- Past history: (Diseases other than presenting complaints for which earlier treatment was taken or hospitalization has been done with year)
- Treatment history: (Any treatment taken for present complaints and for any other complaints earlier with duration)
- Family history: (any major illness in family member???s esp. Maternal and paternal sides)
- Sexual History: (Frequency, desire, any complaints during the process or related to it, any history of masturbation, dhat, nightfall???s. Any other symptom or point of significance)
- Occupation history: (How has been the study period, Ambition in life, any frequent change of jobs and why, Preset occupation and satisfaction with the occupation)
- Obstetrics history: ( No of pregnancy/ any h/o abortions and type/ type of delivery and any complications during pregnancy or after delivery)
- Personal history:
??? Diet : veg/ nonveg
??? Appetite : (any variation with complaints) good/ bad/ amount of food taken
??? Craving: liking for any specific food items. Prefer spices/salty/sweets/bland/hot food/cold food
??? Aversion: disliking for any specific food item.
??? Aggravation: Any food items which cause any problem like acidity etc.
??? Thirst: Quantity of water consumed in a day? Any particular preference of hot / cold water or of any kind of liquid.
??? Addiction: what kind of addiction and for which stimulant? Quantity consumed in a day? Since how long is the addiction?
??? Urine: Any problem
??? Stool: satisfactory/unsatisfactory/ frequency/ constipation/any other problem
??? Perspiration: Part of the body/ much sweating/ any stains left after sweating/ any bad smell from the sweat and what kind
??? Thermal: Comfortable in which kind of climate? As compared to others feel hotter in summers or colder in winters? Does required to take covers all around the year or only in winters
??? Sleep : refreshing/ non refreshing/ sound or not/ hours of sleep/ if disturbed then reason
??? Dreams : any frequent dreams/ or any repetitive dreams
??? Any frequent attacks of any disease of digestion / cold cough/ any other problem
??? Menstrual history: Last menstrual date/ age of onset/ duration/ amount of flow and with or without clots/complaints before during or after menses.
??? Looks / Appearance: (please describe your main facial features and body makeup)
??? Childhood history ( milestones normal/ delayed ; nature as a child, general impressions about the upbringing regarding values/ discipline / social / spiritual aspects ; any stressor/ trauma/ major life incident having an impact on as a individul)
??? Emotions: How you are as a person, which things affects you profoundly and your reactions towards them. How often do you get angry and how you behave in anger, when get hurt, embarrassed etc.
??? Thoughts : any persisting thoughts/ concentration level/ any sexual thoughts interfering with normal life
??? Concentration and memory: any problems faced regarding maintaining of concentration? Any loss/weakness of memory? Also mention the duration for which the problem might be there.
??? Nature: How are you by nature, Please focus more on your negative points?
??? How do you solve your conflicts with others and yourself?
??? Any major change in life which has affected you profoundly
??? How the present disease has affected you mentally, any concerns related to present disease, any fears related to present disease. Any cause / condition after which the complaints started.