Consent Form "*" indicates required fields CQRASC Consent Form for Telephone/Video Consultation and Telephone/Email contact Name* First Name Last Name D.O.B* DD slash MM slash YYYY a) I have been made aware that telehealth appointments through Gentu software would be the first preference due to privacy and confidentiality requirements. I have been made aware that Skype/Facetime/Zoom/Google Meet /Teams and other online platforms do not have high end grade encryption and therefore may not meet privacy requirements. b) I understand Skype/Facetime/Zoom/Google Meet/Teams and other online platforms may not be a confidential method of communication. c) I further understand that there is a risk that Skype/Facetime/Zoom/Google Meet/Teams and other online platforms communication between Dr Sudhakar Koduri and myself or between Dr Sudhakar Koduri and other health professionals or agencies regarding my medical care and treatment may be intercepted by third parties or transmitted to unintended parties. d) I understand that email is not confidential method of communication e) I further understand that there is a risk that email communications between Dr Sudhakar Koduri and myself or between Dr Sudhakar Koduri and other health professionals pr agencies regarding my medical care and treatment may be intercepted by third parties or transmitted to unintended parties. f) I understand that in an urgent or emergent situation I should not rely on email for the transfer of information. I have read and understood the above mentioned* Yes No I hereby consent Dr Sudhakar Koduri and his clinic staff to communicate with me, regarding aspects of my medical care and treatment, through the below methods Gentu* Yes No Skype/Facetime/Zoom/Google Meet /Teams and other online platforms* Yes No Email* Yes No Telephone* Yes No Date* DD slash MM slash YYYY Signature*
