1. I understand that I have chosen to engage in a video consultation with the purpose of assessing and treating my medical condition and/or obtaining general medical advice.

2. I confirm I understand how video consultation technology will be used and this consultation will not be the same as a direct patient/healthcare provider visit since I will not be in the same room as my healthcare provider.

3. I understand that I may benefit from telehealth, but that results cannot be guaranteed or assured

4. Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to my primary care provider’s office (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.

5. Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment; (ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold AVANTCARE responsible for lost information due to technological failures.

6. I understand that the level of care provided by my AVANTCARE provider is to be the same level of care that is available to me through an in-person medical visit. While a telehealth visit with an AVANTCARE healthcare provider may reduce my need for a physical visit to a clinic or ER by up to 40%, however, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest medical center, hospital emergency department or other appropriate health care provider.

7. While AVANTCARE provides telemedicine consultations for a wide variety of complaints including urgent care complaints, I understand that the service is not intended for emergency consultations and I am aware that I need to contact local emergency services in case of any doubt. In an emergent consultation, I understand that it is my responsibility to advise my local practitioner and that the telehealth provider’s responsibility will conclude upon the termination of the video conference connection.

8. I may discuss these risks and benefits with my AVANTCARE provider and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to future treatment by AVANTCARE

9. Since my doctors do not have the opportunity to meet with me face-to-face, they must rely on information provided by me or my onsite healthcare providers. AVANTCARE doctors cannot be responsible for advice, recommendations and/or decisions based on incomplete or inaccurate information provided by me or others.

10. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my telehealth care provider (AVANTCARE) or I can discontinue the video consultation if it is felt that the connection is not adequate for the situation.

11. I understand that this service is solely provided by AVANTCARE. My insurer and/or TPA are not directly involved in providing medical consultations and hold no liability for any claim, from any party, arising directly or indirectly from the services provided by AVANTCARE.

12. I understand that I can ask that the telemedicine exam and/or video conference be stopped at any time and for any reason.

13. I understand that my healthcare information (for example but not limited to, diagnosis code and description along with procedures and medications, family history, medical history, allergies, etc.) may be shared with other individuals for claim adjudication and processing, scheduling and billing purposes.

14. I understand and am aware of the alternative treatment options available to me, and I am choosing to participate in a video consultation. I understand that if I have any questions regarding the risks, benefits and alternatives I am able to contact AVANTCARE support staff for detailed clarification. I understand the information will be provided to me in a language I understand.
These risks include, but may not be limited to:

• In rare cases, information transmitted may be insufficient for healthcare decision-making.
• Disruptions can occur due to failures of electronic equipment or internet connection.
• In rare cases, a lack of access to full and complete health records may result in adverse drug interaction or other errors.
• In rare cases, security breaches may occur causing a breach of confidentiality.

15. I understand that I have a right to access my medical information and copies of medical records in accordance with Saudi law. Furthermore, I understand that the laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my call is generally confidential.

16. I understand that as per Saudi law, I can lodge a complaint against my telehealth care provider through the following channels:
a) To AVANTCARE by sending an email to
b) To the Saudi Ministry of Health by contacting: 937

17. I understand that I have the right to withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
By checking the box and beginning the video consultation, I certify that:

• I have read or had this form read and/or had this form explained to me.
• I fully understand its contents including the risks and benefits of using the service.
• I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
• I freely give consent and volunteer to engage in this telemedicine consultation.
• I authorize AVANTCARE and its doctors and physicians to review my medical details, discuss my health with me, and provide treatment advice as necessary.

18. I understand that the calls may be recorded for quality assurance and training purposes.

19.By using the Service, you consent to receiving certain electronic communications from us as further described in our Privacy Policy. Please read our Privacy Policy to learn more about your choices regarding our electronic communications practices. You agree that any notices, agreements, disclosures, or other communications that we send to you electronically will satisfy any legal communication requirements, including that those communications be in writing.