I, name (Name of the person providing consent) hereby provide consent for myself/ my relation (relation) whose name is name (Patient name ); Age: age yrs; Sex gender; ID proof provided number idproof (Aadhar Card/ Driving Licence/ PAN Card of person giving consent) to participate in telemedicine consultation with Dr Mallika Goyal, MD, DNB, Reg No 12950 (MCI), Consultant Ophthalmologist & Retina-Uveitis Specialist at Apollo hospitals, Hyderabad, India.

I am aware that telemedicine consultation has limitations that the doctors diagnosis & treatment is based on the information provided and limited visual inspection of images or videos with inadequate magnification.

I have chosen telemedicine consultation because I am unable to attend 'in person consultation' and I am aware that if required, I may still be advised 'in person consultation' at the conclusion of this telemedicine consultation. I agree to make all efforts to undertake the same.

I hereby state that I shall not withhold any relevant information/ document from the Doctor and I undertake to provide all investigation reports as advised. I also agree to schedule follow up consultation as advised. I may revoke/ cancel my consent at any time by contacting the said doctor.

As long as this consent is in force, Dr Mallika Goyal, MD, DNB, may provide health care services to me via telemedicine without the need for me to sign another consent form.

Full name of patient: name
Age of patient: age
Date: age
Time: age

Full name of person giving consent: name
Age of person giving consent: age
Relation with patient: age

Date: date
Place: address