Patient's Name
Address
Age
Sex
Date of Birth
Occupation
Contact #
Have you traveled outside the Philippines in the past 21 days? *
If YES, where?
Have you had any of the following symptoms in the past 14 days? *
Affected Eye
Reason for consult (please check all applicable) *
Current Eye Complaint
Upload your eye photo below.
Past Medical and Surgical History
(please check all applicable)
Medications
Allergies
Family History
(please check all applicable)
Visual Acuity Testing
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Ensure proper room lighting and set phone/ computer brightness to 100%.
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Hold the screen 4 feet (1.2 m) from you .
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Test each eye one at a time by covering the other eye using the palm of your hand.
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Choose the smallest line that you could read clearly and record it below for each eye.
Right Eye
Left Eye
Please take time to read the information below prior to your teleophthalmology appointment with our eye doctor. Should you decide to consent to this method of treatment check the consent button below and click the submit button.
TELEOPHTHALMOLOGY INFORMED CONSENT:
(1) You may withhold or withdraw your consent at any time without affecting your right to future care or treatment.
(2) The laws that protect the confidentiality of your medical information also apply to teleophthalmology. The information disclosed by you during the course of your treatment is generally confidential. Exceptions to confidentiality laws include the requirements to protect you or the public from serious harm; report abuse or neglect of children, the elderly, or people with disabilities; and respond to an order from a court. St. Martin Eye Clinic will be using wix.com website platform with cloud service to store information gathered on this form. However, even with these privacy and security measures in place, there are still risks associated with teleophthalmology and the SMEC.
(3)St. Martin Eye Clinic will be using Zoom and or Facebook as its remote service platform. Zoom encrypts all audio, video, and screen sharing data as a means of protecting your personally identifiable information. All recording capabilities should be turned off.
(4) Your provider will inform you of their location at the time of your appointment and you agree to provide your location as well. In the event of an emergency, you should seek local emergency services. In a non-emergent situation, if you or your provider believes you would be better served by in-person service, we will work with you to make other arrangements for care.
(5) All medical reports resulting from the telemedicine visit are part of your medical record. All existing laws regarding access to your medical information and copies of your medical records apply.
(6) You agree not to record your telemedicine visit. You agree to conduct the appointment in a setting that allows you to hear and to be heard and seen clearly by your health care provider.
Informed Consent
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