Virtual Care & Email Communication Policy and Consent Form

• Dixie Road Family Health Organization will contact you by email to send you:

Appointment bookings and reminders

Referral bookings

General information about our office and clinics

Certain test results if your doctor has specifically discussed and agreed to this option

• Please tell us which email address you wish us to use. Don’t forget to inform us of any changes to your email address.

• If you intend to receive our emails, please remember to update your address book with the following and/or to check your junk/spam folder. *

• There are some privacy risks in using email: *

Email is not secure. While we try to protect our emails we cannot guarantee the security and confidentiality of any email you receive from us. As the message leaves Dixie Road Family Health Organization, it is sent across the internet and it could be intercepted and read.

Emails we send to you may be filed on your health record depending on the email message and can become a permanent part of your health record. Emails can be used as evidence in court.

Email is easy to forge, easy to forward (sometimes accidentally and to many people) and may exist forever.

If you use a work email, your employer may have a right to archive and inspect emails sent from their systems. We recommend you avoid using a work email address.

Dixie Road Family Health Organization is not responsible for information loss due to technical failures

Virtual Care Policy & Consent *

I understand and accept the risks related to unauthorized disclosure or interception of personal health information via virtual medicine, and know that I need to be in a private setting using my own computer/device.

I understand that care provided through video or audio communication cannot replace the need for physical examination or an in person visit for some disorders or urgent problems and the I understand the need to seek urgent care in an Emergency Department as necessary

I know that :

• Email should never be used in an emergency. If you have an emergency, you should call 9-1-1 or go to your nearest hospital emergency room or health care provider immediately.

• Email should never be used for urgent problems (where you need a response from us by a certain time). If you have an urgent issue, you should call the office and make an appointment to see your Dixie Road Family Health Organization health care provider.

Patient Acknowledgment, Agreement and Release: *

• I have read and fully understand this consent and release form.

• I understand the risks associated with using email with Dixie Road Family Health Organization and I accept those risks.

• I understand the limits set out for using email with Dixie Road Family Health Organization and I agree to follow those limits.

• I understand if I no longer wish to receive Dixie Road Family Health Organization emails, I will write to bernadette.kieley@bellnet.ca.

• RELEASE OF LIABILITY: I agree that Dixie Road Family Health Organization (and their physicians, staff, agents and officers) shall not be responsible for any personal injury including death, and/or privacy breach (outside the control of Dixie Road Family Health Organization) or other damages as a result of my choice to receive emails from the Dixie Road Family Health Organization and I release the Dixie Road Family Health Organization (and their physicians, staff, agents and officers) from any liability relating to communicating with me by email.

• I understand that Dixie Road Family Health Organization may choose not to deal with me by email if I am not able to follow the email rules or if the Dixie Road Family Health Organization changes its email program.

• If I had any questions about this form, I have asked Dixie Road Family Health Organization those questions and agree that my questions have been answered.

• I understand I have the right to have legal advice about signing this form and what it means to me and I have either sought that advice or chosen not to seek such advice.

SIGNATURE OF PATIENT/SUBSTITUTE DECISION-MAKER

Clear

Print Name & HC Number

please ensure you add your Health Card Number to your name for ID verification

Date

Contact Us

Working Hours

Pages

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