FV HOSPITAL’S STATEMENT

Telemedicine Services means the delivery of medical services using interactive audio and visual electronic systems between a hospital and a patient that are not in the same physical location. These services may include teleconsultation, ordering of investigations, prescription, distribution of patient education materials or other medical services.

1. The potential benefits of telemedicine are:

• Avoiding the need to travel to FV hospital.
• A reduced waiting time to see the doctor.
• Increasing access to care.

2. The potential risks with this technology are:

• The video connection may not work or it may stop working during the teleconsultation.
• The video picture or information transmitted may not be clear enough to be useful for the consultation.
• The patient may be required to go to FV Hospital if the information obtained via telemedicine was not sufficient to make a diagnosis.

STATEMENT OF PATIENT/PATIENT’S GUARDIAN

I understand the following:

• A teleconsultation is done through a two-way video link-up whereby the doctor can see my image on the screen and hear my voice but cannot examine me then such a consultation may not be equal to a face-to-face visit.
• The doctor being unable to perform a physical examination must rely on information provided by me and cannot be responsible for advice, recommendations and/or decisions based on incomplete or inaccurate information provided by me.
• The doctor will determine whether or not my condition is appropriate for a teleconsultation and may recommend a face-to-face consultation.
• Telemedicine may involve electronic communication of my personal medical information to other doctors of FV Hospital or other healthcare facilities when appropriate.
• Other individual may be present during the teleconsultation to operate the video equipment and assist the doctor but reasonable steps will be taken to maintain the confidentiality of the information obtained.
• FVH Hospital can record, save and store all teleconsultations, instant messaging chat, text messages, audios and videos transcripts, emails and hard copy correspondences with me/my dependent for record purposes.
• FV Hospital and its medical staff cannot give me a guarantee that the teleconsultation will improve my/my dependent’s condition.

I agree with my obligation for payment prior to the teleconsultation.

I understand that any disputes regarding my consent to the Telemedicine Services provided to me/my dependent are governed by, and shall be construed in accordance with, the laws of Vietnam and I irrevocably agree that the courts of Vietnam shall have exclusive jurisdiction to settle any disputes which may arise out of, under, or in connection with, my consent or the services provided to me/my dependent and for those purposes I irrevocably agree to submit all disputes to the exclusive and final jurisdiction of the courts of Vietnam, without regard to any conflict of law principle

EQUIPMENT LOAN

For the purpose of teleconsultation for Covid-19 patient, FV Hospital agrees to lend the equipment to the person specified in the reqest for equipment loan, including pulse oximetry and temperature measuring devices, in accodance with the terms of this Equipment Loan Agreement. Total deposit amount is VND 5,000,000.

The devices will be used by the patient for free of charge during 12 days included in the FV Covid-19 telemedicine package. After these 12 days, the patient must return the devices to FV hospital. The late fee will be charged at VND 300,000 for each day of delayed return.

AGREEMENT TO TERMS OF EQUIPMENT LOAN AND ACKNOWLEDGEMENT OF USE

By signing this form, I agree to borrow the above named equipment upon the terms and conditions stated herein for use by me/my dependent.  I further agree to be responsible to maintain the equipment in good condition and to protect the equipment from water and moisture, to ensure the equipment is only used for the purpose for which it was intended and to return the equipment on the Requested Return Date specified above.  I understand that should any damage be caused to the equipment whilst it is in my/my dependent’s care that I may be liable to compensate FV Hospital therefore up to the full replacement value, subject to FV Hospital’s policy and discretion.  I further understand and agree that should I/my dependent return the equipment after the Requested Return Date specified above, I will be subject to payment of the daily Late Fee noted above.  The late fee will be VND 300,000 per day after 12 days since the date you receive