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I understand that virtual consultation is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider. Electronically transmitted information may be used for diagnosis, treatment, follow-up, and/or patient education, analysis, research and may include any of the following: Patient medical records; Medical images; Interactive audio, video, and/or data communications; and/or Output data from medical devices.

By signing this form, I am consenting to participate in virtual consultation. I am acknowledging that I have read and understand the provisions in this form. If I am unable to read, I am acknowledging that health care provider has read & explained this form & how virtual consultation service works to me. And I have authorized IPH clinics – Super-Specialist doctors / medical personnel /para medical staff to administer self-examination and plan of care during the course of all the sessions of patient care. By this undersigned I also consent them to use my medical information for research & analysis purpose.

I hereby give my informed consent for the use of virtual consultation in my medical care. I hereby authorize IPH Women Clinics – Purpozo Brands Private Limited to use virtual consultation in the course of my diagnosis and treatment. For any dispute, jurisdiction Ahmedabad, Gujarat, India only.