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Patient Consent & Notice Template

For physiotherapists using PhysioAI EMR (com.physioai.emr). You are the Data Fiduciary for patient data — show a DPDP §5 notice + collect §6 consent before entering data. Copy, letterhead, translate to Eighth-Schedule language if needed. This is a template, not legal advice.

Copy-ready notice (fill [brackets])

[Clinic letterhead — Clinic name, address, therapist name, registration no., contact]

Patient Privacy Notice — Physiotherapy Care Records (PhysioAI EMR)

Dear Patient, to provide physiotherapy care we record your personal and health information in PhysioAI EMR (operated by Auraflex Intelligent Healthcare Services Pvt. Ltd., Karjat, on our instructions; storage via Supabase).

What we collect: name, age/DOB, sex, phone, email, occupation, condition, complaints, medical/surgical history, allergies, medications, family/social history, goals; SOAP notes; assessment scores (e.g. Berg Balance); exercise protocols/prescriptions; appointments/home visits; invoices/payments; reminders (WhatsApp/SMS/push); voice intake audio/transcript only if you agree to recording.

Purpose: diagnosis support, treatment planning, scheduling, home programs, billing, reminders, safety alerts, legal record-keeping. We do not use your data for marketing or AI model training.

Retention: clinical records care + 3 years (MCI rule); billing 8 years (tax law); voice audio 30 days unless saved as intake; reminders 12 months. Then anonymised/deleted unless law requires longer.

Sharing: only with processors to run the EMR (listed in EMR Privacy §8), or as required by law. No sale.

Your rights: access summary, correction, erasure, nomination, grievance redressal (DPDP §§11–14). Contact us at [clinic email/phone] first; EMR support: support@physioai.in. You may complain to the Data Protection Board.

Withdrawal: you may withdraw consent anytime — as easy as giving. We stop + cause processors to stop within reasonable time; prior lawful use unaffected. Withdrawing may limit care continuity; we will explain alternatives.

Children (under 18): parent/guardian must consent below.

Consent checkboxes (tick + sign)

  • I have read the notice above (or it was read to me in [language]) and I consent to collection/use of my health information for physiotherapy care in PhysioAI EMR.
  • I consent to appointment / exercise / payment reminders via WhatsApp / SMS / push to [phone]. I can opt out anytime.
  • Voice recording (optional, separate): I consent to audio recording for intake transcription. I understand I can decline and give history verbally/in writing instead.
  • For under-18 patient: I am the parent / lawful guardian of [minor name, DOB] and consent on their behalf.
Patient (or guardian) name / signature / date / phone: ___________________________
Therapist / witness name / signature / date: ___________________________

Store signed copy with clinical record. If consent refused → do not enter PHI; offer non-digital alternative and document refusal. If emergency (§7(d)) without consent → document ground, obtain consent as soon as practicable.

Therapist checklist

  • Notice shown before collection, in language patient understands. No bundled consent — separate ticks above.
  • Verify AI voice extraction before saving — never save hallucinated meds/allergies/scores.
  • Honour withdrawal: suppress comms (72h best-effort), delete/restrict per Privacy §12–§13.
  • Never enter other-clinic patient data you have no right to process; never publish PHI to public profile.
  • Full duties: EMR Terms §4–§5 · EMR Delete