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Register for Telemedicine consultation

  • Personal information
  • Terms and conditions
  • Choose clinic and confirm
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Terms and Conditions

I voluntarily consent to accept the telemedicine consultation from BDMS Wellness Clinic’s physician, dentist, medical staff, collectively “Provider”, and I agree and acknowledge that my medical information and Personal Information shall be recorded in voice, video, and photography.

  1. I understand that the telemedicine consultation in cooperation with BDMS Wellness Clinic is to provide clinical guidance for diagnosis and treatment in addition to the standard of care provided at BDMS Wellness Clinic.
  2. I understand that the telemedicine consultation will provide me with a consultation opinion using interactive audio, video, or data communications.
  3. I understand that the telemedicine consultation based services and care may not be as complete as face-to-face services and I will not receive a detailed treatment plan.
  4. I understand that at the conclusion of the telemedicine consultation, I may be invited to visit BDMS Wellness Clinic if further diagnosis and/or treatment is required.
  5. I understand that the telemedicine consultation also involves the communication of my medical information or personal information that could identify person directly or indirectly, including but not limited to the medical records and contact information (“Personal Information”) for the purpose of the telemedicine consultation, both orally and visually, to the Provider. The Personal Data Protection Act, B.E. 2562 (2019) also apply to the telemedicine consultation. However, I understand and accept that the Provider can collect, use, disclose, and access to all the Personal Information I provide in the purpose of diagnosis and treatment only.
  6. I understand and accept that my Personal Information may be used by or cross-border transferred to the Provider and/or a third party for the purpose of diagnosis and treatment.
  7. I understand that any copy of my consultation videos will be held by BDMS Wellness Clinic for a period of five years.
  8. I understand that there are risks and consequences from the telemedicine consultation, including, but not limited to the possibility, despite reasonable efforts on the part of my Provider, that the transmission of my Personal Information could be disrupted or distorted by technical failures the transmission of my Personal Information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
  9. I understand that if information or the clarity of virtual communication is not enough during the services provided such as the lack of clarity of picture and sound, lack of medical record or an x-rays is required, a telemedicine consultations may not be provided by a physician or dentist.
  10. I understand that should the provider cannot provide a telemedicine consultation, I may be contacted by the Provider through other channels such as telephone, Line application, or Facebook, and etc.
  11. I understand that there are potential risks and benefits associated with any form of the medical treatment, and that despite the efforts of my Provider, my condition may not be improve, and in some cases may even get worse. Therefore, I understand that I may benefit from the telemedicine consultation, but that results cannot be guaranteed or assured.
  12. I have no other pre – existing medical conditions that have not already been disclosed here.
  13. I also understand that omitting the Personal Information or misinforming the Provider may result in an inaccurate consultation.
  14. I understand that a rate of fee, terms and conditions of a telemedicine consultation will be designated by the Provider.
  15. I have discussed with the Provider, and all of my questions have been answered to my satisfaction.
  16. I have read and understood the information specified in this consent form thoroughly.
Please accept the terms and conditions.
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