Patien­t’s Full Name (required)

Gen­der of Patient: (required)

MaleFemale

Patien­t’s Date of Birth (required)

Your City & Country 

Desired date and time for appointment 

(Note: please allow 48 hours for confirmation 

Desired local time for appointment 

Select Type of Consultation 

(Note: the length of ses­sion varies accord­ing to the type of consultation)
—Please choose an option—Counseling SessionInformational CarePsychotherapyPsychoeducation

Details rea­son for this Consult 

(Please type as much detail as possible 

Guardian’s Name if patient is a minor 

Your Phone Num­ber, includ­ing coun­try & area code (required)

Email for con­fir­ma­tion (required)

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Telepsy­chi­a­try by www.pakpsychiatrist.com is pro­vid­ing psy­chi­atric ser­vices, via Skype, Google, etc. in which the clin­i­cian and the patient are not at the same loca­tion. Ben­e­fits to telepsy­chi­a­try include increased access to care and patient con­ve­nience. Poten­tial risks include, but may not be lim­it­ed to: infor­ma­tion trans­mit­ted may not be suf­fi­cient (poor res­o­lu­tion of video); may not pro­vide for or arrange for emer­gency care; delays in med­ical eval­u­a­tion and treat­ment due to defi­cien­cies or fail­ures of the equip­ment; secu­ri­ty pro­to­cols can fail, caus­ing a breach of pri­va­cy; and a lack of access to all the infor­ma­tion avail­able in a face to face vis­it may result in errors in med­ical judg­ment. Alter­na­tive to telepsy­chi­a­try include tra­di­tion­al face to face ses­sions which is not avail­able via this site. 

I Under­stand and Con­sent to Telepsychiatry 

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Rights: 1) I under­stand that the laws that pro­tect the pri­va­cy and con­fi­den­tial­i­ty of med­ical infor­ma­tion also apply to telepsy­chi­a­try; 2) I under­stand that the Skype tech­nol­o­gy used by www.pakpsychiatrist.com is encrypt­ed to pre­vent the unau­tho­rized access to my pri­vate med­ical infor­ma­tion; 3) I have the right to with­draw my con­sent to the use of telepsy­chi­a­try dur­ing the course of my care at any time. 4) I under­stand that www.pakpsychiatrist.com has the right to with­hold or with­draw con­sent for the use of telepsy­chi­a­try dur­ing the course of my care at any time; 5) I under­stand that all rules and reg­u­la­tions which apply to the prac­tice of med­i­cine in the Pak­istan also apply to telepsychiatry.* 

I Under­stand and Con­sent to Rights 

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Respon­si­bil­i­ties: 1) I will not record any telepsy­chi­a­try ses­sions with­out the writ­ten con­sent of www.pakpsychiatrist.com and I under­stand that www.pakpsychiatrist.com will not record telepsy­chi­a­try ses­sions with­out my con­sent; 2) I will inform Dr. Rana if any oth­er per­son can hear or see any part of our ses­sion before the ses­sion begins. Like­wise, Dr. Rana will inform me if any oth­er per­son can hear or see any part of the ses­sion before the ses­sion begins. 

I Under­stand and Con­sent to Responsibilities 

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Pay­ment of Ser­vices: Telepsy­chi­a­try is a new field and billing rules are not well defined. I under­stand that I will be pay­ing for the ser­vices and will receive a receipt which I may send to my insur­ance com­pa­ny. I may or may not be reim­bursed for this service. 

I Under­stand and Con­sent to Pay­ment of Services 

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“I have read and under­stand the infor­ma­tion pro­vid­ed above regard­ing telepsy­chi­a­try. I give my informed con­sent for the use of telepsy­chi­a­try in my med­ical care and autho­rize www.pakpsychiatrist.com clin­i­cians to use telepsy­chi­a­try in the course of my diag­no­sis and treatment.” 

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Attach any form for review? 

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