Sumedha Clinic
Sumedha Clinic

OPENING:
Monday to Saturday
6pm to 9pm

Call Us:
040- 35589024 , +91 9347910074

Email:
sumedhaclinic09@gmail.com

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Sumedha Clinic>Follow-up Form

Follow-up Form

    Consent Form

    Yes, I consent to avail consultation via telemedicine. I know the potential risks, consequences and benefits of telepsychiatry consultation. I will ask doctor or pharmacist, if I do not understand any of the information provided in the prescription. I will stop prescribed medicines in case of any adverse reaction/side effects, I will contact the psychiatrist immediately or go to the nearest registered medical practitioner for in-person consult.

    Note:

    Filling this proforma will facilitate

    1. To understand what information and history is required for effective consultation. Adequate and reliable information that is required for arriving at a provisional/definitive diagnosis.
    2. Arriving at diagnosis and planning treatment management.
    3. Psychiatrist to effectively spend time with the patient during consultation rather than documentation during the consultation.
    4. Please do remember that online consultation time is fixed per session. The average online consultation time is approximately 10 to 15 minutes, which is similar to in-person consultation time.
    5. Filling this proforma by patient/family members is optional.
    6. This proforma will be retained in the patient's file in the hospital along with a copy of all the investigations and a copy of the prescription.

    Information to the patient and patient's family members

    1. Presence of patient is advisable during the telemedicine consultation. This is as per the Telemedicine Practice Guidelines-2020 and Mental Healthcare Act, 2017.
    2. If the patient is not willing to come for telepsychiatry consultation, please follow Mental Healthcare Act, 2017 and request for in-person consult or home visit by the mental health care professionals for Mental Capacity Assessment (please, check if home psychiatric service is available).
    3. The Telemedicine Practice Guidelines have stated (Code 4.1.1.2) that the patient/patient's family member will be responsible for the accuracy of the information shared with the doctor. Please read Telemedicine Practice Guidelines available online from MoHFW, New Delhi.
    4. If symptoms are severe and/or severe side effects of medicines and/or emergency care is required, please do not wait for telemedicine consultation appointment. Please do in-person consultation at the nearest psychiatrist or registered medical practitioner at the earliest.
    5. Neither of the party (patient/patient's party or psychiatrist) will not do audio or video recording, without prior explicit consent. Covert recordings (audio or video) are illegal since everyone being recorded must consent to be recorded. Explicit consent is must from all the parties.

    Follow-up Consult Proforma

    Proforma complies with MHCA, 2017 Sec 25 and the Mental Healthcare (Rights of Persons with Mental Illness) Rules, 2018 Rule 6(3), Form B.

    To be filled by Psychiatrist

    If the patient develops signs and symptoms from non-psychiatry specially during follow-up consult, please do refer him/her to the respective specialist(as a first consult) explaining the need for such consultation similar to in-person consult. please continue to treat, if the patient has new symptoms in psychiatry specialty)

    Desclaimer

    This telepsychiatric consultation is based solely on the history and information provided by the patient/attendant and is subject to the limitations of teleconsultation. The consulting psychiatrist may, at their sole clinical discretion, defer, discontinue, or decline teleconsultation and advise an in-person evaluation, physical examination, investigations, or referral whenever considered necessary. This service is not intended for psychiatric or medical emergencies. In cases of suicidal ideation, violent behaviour, altered consciousness, or any emergency, seek immediate care at the nearest hospital or emergency department. By proceeding, the patient provides informed consent for telepsychiatric consultation and acknowledges these limitations.