Name of Applicant Health Professional *

First Name

Last Name

Your Phone *

(###)

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Phone *

(###)

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Name of Hospital Director *

First Name

Last Name

Will the hospital make sure to inform the answering Specialist of the outcome of each referred case? *

Yes

Name of person who your cases will be handed in the event you leave this hospital or clinic *

First Name

Last Name

Do you, all responsible clinicians, the hospital director, & your medical centre agree with the following? * LEGAL DISCLAIMER: The specialists agree, in writing, with the Swinfen Network on OpenTelemed.Org and via the Swinfen Network on OpenTelemed.Org (hereon "the Platform"), the medical workers: (a) to undertake appropriate engagements facilitated by the Trust; and (b) to take responsibility, within their own jurisdictions, for their compliance with their own regulatory obligations and for their own professional indemnity cover, in relation to providing telemedicine assistance. The medical workers agree, in writing, with the Platform, the specialists, that they: (a) will receive the specialist assistance on the basis that they will make their own professional judgements about accepting the facilitated assistance and the medical action to be taken, in the particular local conditions and legal environment and not place any formal reliance on the specialist assistance; (b) take responsibility for their compliance with their regulatory obligations and professional indemnity cover within their own jurisdictions, including in relation to receiving telemedicine assistance in this way; (c) recognise the limitations inherent in the remote transmission of such assistance. The patients agree, in writing (as far as possible) to accept treatment from the medical workers operating on the above basis, recognising they are not receiving medical care from the specialists and the limitations inherent in the remote transmission of such assistance. The specialists, medical workers and patients agree, in writing, that the Platform is acting as a facilitating intermediary and not as a provider of any medical advice, assistance, or medical referral services. * *

Yes, I understand and agree.