Psychiatrist | Compassionate Mental Health Care • Guidance • Treatment • Healing — Dr. Nueva Joy Perucho is a General Psychiatrist with expertise in a range of psychiatric issues, including trauma, psychosis, mood disorders (such as depression and bipolar disorder), anxiety, and neurodevelopmental disorders. She employs a patient-centered, multimodal approach to care, utilizing both pharmacotherapy and psychotherapy. Dr. Nueva graduated with honors from West Visayas State University (Doctor of Medicine) and completed her training in general psychiatry at Southern Philippines Medical Center, where she served as Chief Resident. Fluent in English, Filipino, Bisaya, and Ilonggo, she is devoted to delivering compassionate and personalized care to her patients. ----- Dear Patient, Welcome to our psychiatric tele-consultation service. Please take note of the following guidelines for a smooth and effective consultation: INFORMED CONSENT TO RECEIVE PSYCHIATRIC EVALUATION AND TREATMENT By accepting the booking confirmation, I acknowledge that I am voluntarily giving my informed consent to receive psychiatric evaluation and treatment from Dr. Perucho. I agree that this consultation is for the improvement of my mental health and well-being. Moreover, I understand that this evaluation shall NOT be used for medicolegal purposes. 1. CONFIDENTIALITY
I agree to share my personal data with Dr. Perucho and her clinic staff to facilitate the scheduling of my consultation and for billing purposes. I understand that all discussions and records are confidential to the extent permitted by law. Information regarding my consultation or the content of our conversations will not be shared without my consent unless permitted by law. However, there are situations in which Dr. Perucho may be permitted or required by law to disclose information without my consent, including but not limited to the following: o a. Information may be disclosed to other members of the healthcare team to facilitate the delivery of professional services to me; o b. Mental health information may be disclosed if such disclosure is necessary to initiate or seek emergency hospitalization of the client or to otherwise protect the client or another individual from a substantial risk of imminent and serious physical injury; o c. Information may be disclosed to comply with laws regarding the reporting of sexual abuse, abuse, neglect, or exploitation by another for minors or other at-risk populations (e.g., elderly and mentally and physically vulnerable populations); and o d. Information may be disclosed when it is required by the court. • Furthermore, in compliance with the Data Privacy Act of 2012, I agree not to take any picture or video when inside the clinic to respect the privacy of other clients. I also agree not to record in video or audio format nor divulge the details of my consultation. 2. MEDICATION
Dr. Perucho will recommend medications that can be used in treatment as deemed necessary. She will also discuss the indications and potential side effects of these medications. I agree that I will not share my medication with anyone else. I also agree that I will not receive other medications from other healthcare professionals without first informing Dr. Perucho. I understand that alcohol and other drugs may compromise my treatment and worsen my symptoms. Moreover, combining alcohol or opiates with benzodiazepines (like clonazepam and alprazolam) could be dangerous and potentially fatal. Hence, I commit to abstaining from these substances while in treatment. 3. MISSED APPOINTMENTS/CANCELLATIONS/LATE ARRIVAL
If I am unable to make a scheduled appointment, I will call to cancel this appointment at least twenty-four (24) hours before the appointment. Otherwise, I will be charged for the appointment. If I fail to show for three or more appointments without notice, or I do not follow up as recommended by Dr. Perucho, I may be referred elsewhere for services. I understand that a “no show” is defined as any of the following: missing an appointment without notifying ahead, canceling an appointment with less than twenty-four (24) hours' notice, or coming late to an appointment. If I arrive fifteen (15) minutes late to an appointment, I understand that my appointment may be cancelled, and I may be charged a “no show” fee equivalent to the consultation fee. 4. URGENT/EMERGENT CONCERNS
I understand that this online consultation service caters exclusively to non-urgent and non-emergency cases. In the event of an emergency (such as suicidal or violent behavior), or urgent medical symptoms, I will proceed immediately to the nearest Emergency Room. Dr. Perucho will not be liable for emergencies or urgent situations that arise during or after a consultation. 5. ADMISSION
I understand that admission may be recommended as deemed necessary by Dr. Perucho. This may be indicated if there is a threat to my safety or to other individuals, if I am unable to take care of myself, or if there is a need for diagnostic services, among others. I understand that Dr. Perucho will discuss the indications for recommending admission to me and to my legal guardian. If my legal guardian and/or I refuse admission, I understand that I will need to sign a waiver. Dr. Perucho will not be liable in such a situation. 6. FEES
I understand that a fee will be charged for every consultation and for additional requests. I understand that I need to pay the fee in advance if I want to reserve a slot for consultation. Fees are as follows: • Initial appointment: Php 2,800 • Follow-up appointment: Php 1,800
Additional fees may be charged for services such as the prescription of regulated/S2 drugs (Php 300.00), requests for Medical Certificates or Abstracts (Php 400.00), Psychiatric Reports ([Not for Medicolegal Use] Php 1,000.00), and signing of Insurance Claims (Php 400.00). Payments can be made via cash, e-wallet, or bank transfer. 7. TERMINATION OF SERVICES
I understand that I may decline further participation or recommended treatment at any time. I also understand that my psychiatric care may be terminated, and I may be referred to another psychiatrist if: • I do not follow the treatment recommendations of Dr. Perucho, including referrals, taking medications as prescribed, and following up in the recommended time frame. • I do not adhere to patient responsibilities (including acting in a courteous and respectful manner in all interactions). Guidelines for Tele-Consultation: • This online clinic caters exclusively to non-urgent and non-emergency cases. In the event of an emergency (suicidal and/or violent behavior) or urgent medical symptoms, please proceed to the nearest Emergency Room. • This online clinic DOES NOT CATER TO MEDICOLEGAL CASES. • Ensure a stable internet connection for optimal consultation. Signal issues may impact the quality of the session, and in case of severe signal disruption, the consultation may need to be rescheduled. Kindly notify us if you experience connectivity issues, and we will accommodate you appropriately. • Direct ALL concerns to the NowServing/SeriousMD app, and responses will be provided exclusively through the platform and only during clinic hours. Clinic hours are available on the profile page. Please be patient as responses may take time, given the doctor’s schedule. • Consultation duration is 40-60 minutes per session. Late logins exceeding 15 minutes will result in forfeiture of the time slot. Missed appointments or no-shows will be charged as a full consultation. Cancellations and reschedules are only accepted 24 hours prior to the scheduled consult. • Consultation platforms: Sessions will occur through the NowServing/SeriousMD app, Zoom, or Google Meet. Unless otherwise specified, your consultation will take place via the NowServing app. Please be prepared 5 minutes before the scheduled time. • Additional documents requiring Dr. Perucho’s signature, such as medical certificates, PWD certification, fit-to-work certificates, medical abstracts, and other documents, will require an additional fee. Medical certificates, prescriptions, and lab requests will be transmitted through the NowServing app. Official receipts are available upon request. • Minors must be accompanied by a parent, relative, or legal guardian during consultation. • Overtly aggressive, actively suicidal, or those with recent attempts must seek immediate consultation at the Emergency Room for prompt management. • Depending on the influx of patients, Dr. Perucho may see you earlier or later, but rest assured that each of you will receive the best care she can provide. I have read this description of services and understand and consent to these policies. I understand that I have an opportunity to discuss any questions regarding the psychiatric treatment services with Dr. Perucho. I also understand the potential risks and benefits associated with psychiatric treatment and that I have the right to make decisions about the psychiatric treatment services I receive, refuse these services, and revoke this consent at any time except to the extent services have already been provided. Based on the information above, I voluntarily consent to receive psychiatric evaluation and treatment from Dr. Perucho. To proceed with your scheduled consultation, please reply with “Acknowledged, I consent.” Thank you.
 Best regards,
 Dr. Perucho and Team