Name of Applicant *

First Name

Last Name

Postal Address

of Applicant hospital, medical centre, or health post

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Name of Hospital Director

First Name

Last Name

Clinician Name(s) *

for those who will use & be responsible for telemedicine referrals & communications

First Name

Last Name

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

Yes

No

Name of person to whom this link will be handed in the event of your leaving this hospital/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 Trust and via the Trust, 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 Trust and via the Trust, 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 Trust 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