remotecare.global

RemoteCare Session Client Consent Form

RemoteCare Client Consent (E)

Date

Time

Client Number:

Client Title

Client First Name:

Client Last Name:

Email:

Mobile

Consent - RemoteCare Session Type

Name of RemoteCare Session Professional:

Institution/Practice details:

PHW/Senior Nurse/DoctorTransferring Client

PHW/Senior Nurse/Doctor Name:

Reason for referring patient for RemoteCare consultations.

Why Consent is needed.

Opt-In

I confirm I have explained to the client reason for transfer to the specialist.

I the Client/My Next of Kin consent to me being referred to the professional health worker

Name of Person Giving Permission

Blood Pressure (Systolic)

Blood Pressure (Diastolic)

Pulse Rate

Respirataryrate

Temprature

Height (cm)

Weight

Consent Image

Upload File

Consent Audio

Upload File

Date of Consent

Time of Consent

Opt-In

By checking, I agree to be transferred to the professional agent identified above.

Back to RemoteCare™

UK +44 (0) 203 939 8035

Ghana: +233 (0) 206 2243997

RemoteCare Client Consent (E)

SERVICE CONTACT

RemoteCare.global

A Mahiri-Telehealth Limited Solution

Telephone: +233 (0) 206 2243997

www.remotecare.global

info@remotecare.global

CONTACT

Mahiri-Telehealth Limited

Email

www.mahiri-telehealth.com

info@mahiri-telehealth.com

SOCIAL MEDIA

UK +44 (0) 203 939 8035

Ghana: +233 (0) 206 2243997

RemoteCare Client Consent (E)

SERVICE CONTACT

RemoteCare.global

A Mahiri-Telehealth Limited Solution

Telephone: +233 (0) 206 2243997

www.remotecare.global

info@remotecare.global

CONTACT

Mahiri-Telehealth Limited Email www.mahiri-telehealth.com info@mahiri-telehealth.com

SOCIAL MEDIA

Mahiri-Telehealth Limited

Email

www.mahiri-telehealth.com

info@mahiri-telehealth.com