Electronic Communications Consent Form
Below is the consent form that you will be asked to sign in order to communicate electronically with our clinic:
I consent to The Christie Clinic (herein referred to as “Clinic) and its staff and/or physicians to communicate with me electronically. By acknowledging this consent form and providing my email address, I acknowledge that I understand and agree to all elements outlined in this document and the Appendix.
I understand that by providing this consent, electronic communication will become the primary method that the Clinic staff and/or physicians will communicate with me outside of an appointment, for both administrative issues and information pertaining to my personal health.
I understand and agree that it is my responsibility to monitor my inbox frequently for important messages from the Clinic staff and/or physicians, and to read and follow through on all communications that I receive, as there may be important information and instructions from my doctor pertaining to my health.
I understand and consent that the Clinic, staff, and/or physicians may share my email address with specialists offices, imaging and lab facilities, and any other institution or professional that I may be referred to as part of my medical care.
I understand that it is my responsibility to ensure that the Clinic has my current email address on file at all times. I will inform the staff of the Clinic in writing if my email address changes, or if I wish to withdraw my consent for further electronic communication.
I understand that common reasons for electronic communication from the Clinic’s staff and/or physicians may include clinic appointment confirmations and reminders; specialist, medical imaging, test appointment information; general clinic-wide announcements; miscellaneous administrative purposes; doctor-initiated communications regarding results, information about my personal health, medical recommendations, and/or next steps in my care.
I understand that I may initiate contact with the Clinic electronically for non-urgent reasons including requesting general information, confirming/cancelling appointments, general administrative requests such as requesting insurance notes and/or transfer of medical records.
I understand that if I request medical advice via electronic communication, that OHIP does not cover this service and an uninsured service fee will apply.
I understand that electronic medical advice is only suitable for simple, non-urgent matters that do not require a physical exam; requests should never be made electronically for emergent, urgent, or serious medical concerns; the doctor will only provide advice electronically if it is safe and appropriate to do so; if my request cannot be handled electronically I may be asked to schedule an in-person appointment; it can take up to 10 business days to receive a response.
I will not hold The Christie Clinic or any of its staff or doctors liable for any outcome that results from my failure to update my contact information including my email address with the Clinic.
I will not hold The Christie Clinic or any of its staff or doctors liable for any outcome that results from my failure to monitor, open, read, respond or act upon electronic communication from the Clinic.
I will not hold The Christie Clinic or any of its staff or doctors liable for information loss due to technical failures associated with my software, hardware, or Internet service provider.
I will not hold The Christie Clinic or any of its staff or doctors liable for any adverse events that may occur as a result of electronic communication.
I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of electronic communications described in this document and the Appendix. I understand and accept the risks outlined in the Appendix to this consent form, associated with the use of electronic communications when interacting with the Clinic’s staff and/or physicians. I consent to the conditions and will follow the instructions outlined in this document and the Appendix. I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communication, it is possible that interacting with the Clinic staff and/or physicians, using electronic communication may not be encrypted. Despite this, I agree to interact with the Clinic physicians and/or staff using these electronic communication with a full understanding of the risk. I acknowledge that either I or the Clinic, staff and/or physicians may, at any time, withdraw the option of using electronic communication upon providing written notice. Any questions I had have been answered.
Name:
Name(s) of dependents you are consenting on behalf of:
Dependents are children under 16y or adults who require your support to communicate electrically.
SIGNATURE
Date
APPENDIX: Risks, Conditions, and Instructions for using Electronic Communication
Risks of using Electronic Communications
The Christie Clinic (herein referred to as “Clinic”), staff, and physicians will use reasonable means to protect the security and confidentiality of information sent and received electronically. However, because of the risks outlined below, the Clinic, staff, and physicians cannot guarantee the security and confidentiality of all electronic communications.
• Use of electronic communication to discuss sensitive information can increase the risk of such information being intercepted by third parties.
• Despite reasonable efforts to protect the privacy and security of information communicated electronically, 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 staff, physicians, Clinic, 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
• Electronic communications can easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.
• Electronic communications 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 Electronic Communication
• The Clinic, staff, and/or physicians cannot guarantee that all electronic communications will be reviewed and responded to within any specific period of time.
• Electronic communication will not be used for medical emergencies or other time-sensitive matters
• If your electronic communication requires or invites a response from the Clinic, staff, and/or 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 Clinic staff and/or 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 Clinic, staff and/or physicians may forward electronic communications or recordings to staff and those involved in the delivery and administration of your care.
• The Clinic, staff and/or physicians are not responsible for information loss due to technical failures associated with your software or internet service provider.
Instructions for using Electronic Communication
To use electronic communication with the Clinic, staff and/or physicians, you must:
• Reasonably limit or avoid using an employer’s or other third party’s computer. Conduct electronic communications in a private setting and using a secure device, where possible.
• Inform the Clinic of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate electronically.
• Include in the message’s subject line an appropriate description of the nature of the communication (e.g. “prescription renewal”), and your full name in the body of the message.
• Review all electronic communications to ensure they are clear and that all relevant information is provided before sending to the Clinic.
• Ensure the Clinic is aware when you receive an electronic communication from the Clinic, staff and/or physicians, such as by a reply message or allowing “read receipts” to be sent.
• Take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.
• Withdraw consent only by email or written communication to the Clinic.
• If you require immediate assistance, or if your condition appears serious or rapidly worsens, you should not rely on electronic communication. Rather, you should call the Clinic or take other measures as appropriate, such as going to the nearest Emergency Department.