Cybersight Telementee Application

Please fill out the following application if you would like to be able to consult with an expert in your field on patient cases or general questions you may have.

If instead you meant to fill out the mentor application, please click here. If you have any questions or concerns, please contact support@cybersight.org.

Eligibility: please note that Cybersight Consult is only available to individuals in developing countries.

1. Name:



2. Contact Information


3. Institution/Hospital Name and Address










5. How did you hear about Orbis Cybersight Consultation? 
5a. Please provide the location and date of the FEH program you attended or will attend.


5a. Please provide the location and date of the HBP program you attended or will attend.


5a. Please specify how you heard about Cybersight.
6. Optional: Are there any Cybersight mentors you wish to be paired with?

Please note: we will take these into consideration, but cannot guarantee that the mentor is available to receive Consultation. If you have more than two preferred mentors, please email support.cybersight.org






Copyright(c) 2003-16 Project Orbis International, Inc.

All worldwide rights reserved.

Orbis Cybersight Agreement 
Between Orbis International, Inc. and:


Scope of Work:


I will use Telemedicine equipment and access to expert physician services provided by Project Orbis International, Inc. (hereinafter called "Orbis") to improve my understanding of eye care disease, pathologies, treatments and best practices in case management. In addition, I will actively participate in the Telemedicine project through the Orbis Telemedicine Website URL www.cybersight.org ("the Website") by using this program to enrich my experience in treating my patients.


Relationship of the Parties:


This agreement is not intended to, or should be construed to establish an employer-employee relationship, partnership, joint venture, agency or similar relationship. I shall not have any right or authority to assume or create any obligation or responsibility, express or implied, on behalf of or in the name of Orbis, or to bind Orbis in any manner, unless authorized in writing by a duly authorized Orbis representative. I shall not make any contrary representation to any third party. I assume full responsibility for my acts in the performance of this agreement.


Payments:

Orbis offers no payments or compensation, and charges no fee to any party for services offered through the Website.


Termination:

Either party may terminate this agreement with written notice within 24 hours of such notice.


Confidentiality:

The nature of this relationship being one that requires access to patient information and Orbis Intellectual Property, I will be bound by absolute confidentiality of information, business procedures, product profiles and other information pertaining to Orbis, unless expressly permitted for publication or dissemination.

    1. Any information, documents, software, technology, date manuals and other materials with relation to Orbis, its activities, business, finding, or associated companies or foundations and all copies thereof supplied by Orbis or prepared, gathered or otherwise obtained by me ("Confidential Information") shall remain property of Orbis and shall be kept confidential by me and not be used by me other than for the benefit of Orbis. 
    2. I shall not transfer divulge any Confidential Information to any other person or organization, unless:
         a. Orbis's prior written consent is obtained; or

                 

         b. The information is already in the public domain, other than through the default of myself; or

                 

         c. Disclosure is required by law.


    3. I shall exercise whatever reasonable means are necessary to protect and safeguard the interest of Orbis and its Confidential Information under the laws of New York State and shall otherwise comply with any other reasonable requirements of Orbis.


    4. The confidentiality requirements contained herein shall remain in full force and effect notwithstanding the expiry or termination of this Agreement.

Terms and Conditions of Engagement with Orbis Telemedicine:


1. I agree that I will use the Website only for medical evaluation, diagnosis and avocation purposes. I agree that I will not use the Website for private and/or personal communication or solicitations of any nature and such use of the Website may result in the termination of this agreement. I acknowledge that Orbis reserves the right to remove material from the Website in its sole discretion.


2. I understand in the course of my consultation with a patient, I may collect information of a personal and       confidential nature ("Personal Information"), including the patient's name, birth date and medical history.


3. I understand that I may use the Personal Information solely in connection with the evaluation, diagnosis and treatment of a patient's condition. In this regard, I may only share the Personal Information with Project Orbis International, Inc. ("Orbis") and third parties Orbis may designate to assist in the evaluation, diagnosis and treatment of a patient's condition.


4. I agree to maintain the confidentiality of the Personal Information.


5. I agree to defend, indemnify and hold Orbis, its affiliates and  associates, including mentors and institutions participating in Orbis programs, harmless for any loss damage or costs, including reasonable attorneys' fees and disbursement, resulting from any third-party claim, action or demand resulting from my misuse of the Personal Information or the Website. 


By signing below, I confirm that I have read, fully understand and agree to the above.



Copyright(c) 2003-16 Project Orbis International, Inc.

All worldwide rights reserved.

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