I hereby confirm that the above information is true and correct and that the Personal Health Number is current and valid.

By supplying my home/cell phone number, email address and any other personal information, I authorize Maple Clinic to use my personal information to contact me with respect to appointment times, referral notices, result information, appointment reminders, and other limited information. I am also aware it is my responsibility to keep my contact information current.

Please note, our clinic does not adopt the result policy of “no news is good news”. I acknowledge that I am responsible for following up on all test results.

I acknowledge that I am responsible for the payment of all charges for any treatment that may not be paid or covered by my Ontario Health Insurance Plan (OHIP), ie. Insurance forms, driver’s physicals, sick notes, employment and sports physicals and transfer of records.

I hereby acknowledge that the medical or other healthcare treatment received by myself from Maple Clinic and any of its physicians will be provided in the province or territory of Ontario, and that courts of Ontario all have the exclusive jurisdiction to hear any complaint, demand, claim, proceeding or cause of action , whatsoever arising from or in connection with that medical or other healthcare and treatment, or from any other aspect of the relationship between the physician and myself.

I also agree that any and all disputes arising from or in connection with that relationship, including any disputes arising under or in connection with this agreement, shall be governed by and construed accordance with the laws of the province or territory of Ontario (other than conflict of laws rules) and the laws of Canada applicable therein.

I authorize this medical practice to access my health information recorded elsewhere – including Pharmanet Medication Profile – for the purpose of providing care and treatment. This consent will continue until I revoke it in writing.

Appendix A - Risks of using electronic communication

The Physician will use reasonable means to protect the security and confidentiality of information sent and received using the Services (“Services” is defined in the attached Consent to use electronic communications). However, because of the risks outlined below, the Physician cannot guarantee the security and confidentiality of electronic communications:

• Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.
• Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information.
• Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
• Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings.
• Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Physician or the patient.
• Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.
• Electronic communications may be disclosed in accordance with a duty to report or a court order.
• Videoconferencing using services such as Skype or FaceTime may be more open to interception than other forms of videoconferencing.
• Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.
• Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.

Conditions of using the Services

• While the Physician will attempt to review and respond in a timely fashion to your electronic communication, the Physician cannot guarantee that all electronic communications will be reviewed and responded to within any specific period of time. The Services will not be used for medical emergencies or other time-sensitive matters.
• If your electronic communication requires or invites a response from the Physician and you have not received a response within a reasonable time period, it is your responsibility to follow up to determine whether the intended recipient received the electronic communication and when the recipient will respond.
• Electronic communication is not an appropriate substitute for in-person or over-the-telephone communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed. You are responsible for following up on the Physician’s electronic communication and for scheduling appointments where warranted.
• Electronic communications concerning diagnosis or treatment may be printed or transcribed in full and made part of your medical record. Other individuals authorized to access the medical record, such as staff and billing personnel, may have access to those communications.
• The Physician may forward electronic communications to staff and those involved in the delivery and administration of your care. The Physician might use one or more of the Services to communicate with those involved in your care. The Physician will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.
• You and the Physician will not use the Services to communicate sensitive medical information.
• You agree to inform the Physician of any types of information you do not want sent via the Services, in addition to those set out above. You can add to or modify the above list at any time by notifying the Physician in writing.
• The Physician is not responsible for information loss due to technical failures associated with your software or internet service provider.

Instructions for communication using the Services

To communicate using the Services, you must:

• Reasonably limit or avoid using an employer’s or other third party’s computer.
• Inform the Physician of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate via the Services.
• Review all electronic communications to ensure they are clear and that all relevant information is provided before sending to the physician.
• Take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.
• Withdraw consent only by phone email or written communication to the Physician.
• If you require immediate assistance, or if your condition appears serious or rapidly worsens, you should not rely on the Services. Rather, you should call the Physician’s office or take other measures as appropriate, such as going to the nearest Emergency Department