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I Mr/Ms/Mrs, would like to state that, I have understood the information provided regarding telemedicine. I hereby give my informed consent for the use of telepsychiatry consultation in my mental health care. At present, I am located at my mentioned address.

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

I hereby authorize Mr/Ms/Mrs and related to me (relationship) and to represent me. He/she will represent and participate in my mental healthcare through telemedicine in the course of my diagnosis and treatment. I understand and accept that there are risks and benefits in assigning a representative for my mental healthcare.