I hereby agree and consent to the following:
I authorize Doctor, PAUL NIMROD B. FIRAZA a Board Certified Urologist to assess my medical history and to provide healthcare services on ‘as is’ and ‘as available’ basis, including prescription of drugs as deemed necessary. I am aware that healthcare services will be provided through telephone or Internet consultation and that there will be no physical examination. I agree that the diagnosis based on telephone 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 medical information (MI) which will include without limitation
(i) physical, physiological and mental health condition, symptoms and history;
(ii) medical test results in connection with the aforesaid; and
(iii) medical records and history which the Doctor may store, use and disclose to the Doctors solely for the purposes of treatment. The Doctor will not publish and disclose the MI to any third person or body corporate without my express written consent, except when mandated by law.
Comments