Last updated: July 2026 · Draft for legal review

Patient Consent & Confidentiality Form

This form records your consent for BRIDGE to coordinate your care and sets out our confidentiality commitment to you. Please read each section before signing below.

1. Consent to care coordination

I understand that BRIDGE will coordinate my referral, appointments, and follow-up with the licensed provider(s) named in my case, and that BRIDGE itself does not diagnose, prescribe, or perform clinical procedures.

2. BRIDGE's confidentiality commitment

BRIDGE will keep my case information confidential, accessible only to the coordinators and clinical staff directly involved in my care, and handled under the Ghana Data Protection Act, 2012 (Act 843) and BRIDGE’s Privacy Policy.

3. Consent to information sharing

I consent to BRIDGE sharing the minimum information necessary with the specific provider(s), laboratory, or travel partner involved in my case, so that my care can proceed. I understand I may withdraw this consent at any time by notifying my coordinator, which may affect BRIDGE’s ability to continue coordinating my case.

4. Acknowledgement

I understand BRIDGE is not a hospital, telemedicine platform, or emergency service, and that in a medical emergency I should call 112 or go to the nearest hospital directly.