Please enable JavaScript in your browser to complete this form.123The “Tibb Online interview” refers to the use of internet and/or electronic communications to deliver or render Tibb treatment services to people from various geographical locations. This allows access to information pertaining to healthcare for the broader community both locally and internationally, in an attempt to educate individuals on the Tibb approach to illness management and health maintenance. This platform of communication includes but is not limited to video- conferencing, telephonic communications or email. The limitations or challenges associated with the “Tibb Online Interview” include internet connection, visual quality of the chosen software, information security and physical examination. Consent *By signing this form, I am fully aware and in agreement with the following:(a) The use of online services for the ‘Tibb Online Interview’ with my Unani-Tibb Doctor as mentioned above. (b) That the ‘Tibb Online Interview’ and all information provided will be treated with confidentiality. (c) That all assessments, management and treatment will be strictly based on information provided by myself, which includes my past medical history. (d) And that the chosen software is not a source of healthcare nor a medical care software. (e) That I acknowledge the risks imposed from limitations of full vitals, physical examination and complete medical assessment. (f) That I may take my own vitals, if possible, to do so. (g) That it is my responsibility to: secure session/s; and information on my device; and at a private location. (h) That I am fully aware that my practitioner may record or take notes from the session for safe keeping. (i) That this service excludes emergencies or unstable patients. (j) That I may discontinue or stop the session at any time *Patient consent to the ‘Tibb Online Interview’ at the Tibb Treatment Centre - I have read and understand the information provided above regarding the ‘Tibb Online Interview’ and therefore, hereby give my informed consent for the ‘Tibb Online Interview’.(a) The use of online services for the ‘Tibb Online Interview’ with my Unani-Tibb Doctor as mentioned above. (b) That the ‘Tibb Online Interview’ and all information provided will be treated with confidentiality. (c) That all assessments, management and treatment will be strictly based on information provided by myself, which includes my past medical history. (d) And that the chosen software is not a source of healthcare nor a medical care software. (e) That I acknowledge the risks imposed from limitations of full vitals, physical examination and complete medical assessment. (f) That I may take my own vitals, if possible, to do so. (g) That it is my responsibility to: secure session/s; and information on my device; and at a private location. (h) That I am fully aware that my practitioner may record or take notes from the session for safe keeping. (i) That this service excludes emergencies or unstable patients. (j) That I may discontinue or stop the session at any time *Patient consent to the ‘Tibb Online Interview’ at the Tibb Treatment Centre - I have read and understand the information provided above regarding the ‘Tibb Online Interview’ and therefore, hereby give my informed consent for the ‘Tibb Online Interview’.NextPatient's Name *FirstLastDate of BirthDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *Contact NumberPreviousNextAddress *Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryDate *Email *Submit