Test | Family Medicine and Urgent Care Clinic

PATIENT INFORMATION

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Last Name*

First Name*

Address 1*

Address 2

City*

Postal Code*

Birth Date*

Sex* MaleFemale

Phone (Home)*

Phone (Cell)

E Mail*

Health Card No.*

Version No.*

Preferred Pharmacy Name

Fax No.

Any Medical Allergies

Emergency Contact Name

Phone

How did you hear about us ? Refer by friend / family memberGoogleShopping in WalmartOther

PATIENT EMAIL CONSENT FORM

I,

consent to the use of email communication with the staff and physicians of Family Medicine and Urgent Care Clinic.

I can expect to receive emails from Family Medicine and Urgent Care Clinic regarding items Such as appointment reminders. Family Medicine and Urgent Care Clinic will ONLY communicate information on follow-up for blood test results but not transmit other personal health information by email that will require a follow-up visit to Family Medicine and Urgent Care Clinic. Email communication is not a substitute for a clinical assessment and the best way to share information with your healthcare provider is in person.

I am aware of the following:

There are some privacy risks in communicating by email.
Email is not considered a secure method of communicating with us. Email messages may not be encrypted on the Family Medicine and Urgent Care Clinic email system. Email can be intercepted, and we cannot guarantee the security and confidentiality of any cm ii communications that you sent to or receive from us.
Emails may be filed on yow- health records depending on the content of the email message and can become a permanent part of your health record. As they can become part of our healthcare records, they may be shared within the Family Medicine and Urgent Care Clinic or third parties if permitted or required by law (including other healthcare providers and OHIP for example). Email can also be used as evidence in a court of law
Email is easy to forge, easy to forward (sometimes accidentally), and may exist indefinitely.
Family Medicine and Urgent Care Clinic is not responsible for information loss due to technical failures.
I will be expected to notify Family Medicine and Urgent Care Clinic in writing should I no longer wish to receive email communications.

Email should not be used to communicate emergencies or time-sensitive healthcare issues. If you are experiencing an emergency, you should call 911 or go to a hospital or health care provider immediately. Appointments with Family Medicine and Urgent Care Clinic are to be made online for all regular non-urgent consultations. We do not have 24-hour per day/7-days per week monitoring of incoming email messages and cannot guarantee a particular response time for an email. It is your responsibility to follow up by telephone if you require a response to an email message.

It is your responsibility to keep your email address up to date with our office and notify us of any changes. We do not recommend that you use a shared email address for purposes of communicating with us, as there may be some information that you do not wish to share with others. Please be advised that if you choose to use a work email address, your employer may have the legal right to inspect and keep emails that are passed through their system. There may be information that you do not wish to share with your employer.

PATIENT ACKNOWLEDGEMENT, AGREEMENT AND RELEASE

I acknowledge that I have read and fully understand this consent and release form.
I understand the risks and limits associated with communicating with Family Medicine and Urgent Care Clinic by email and I accept those risks and limits.
I agree that Family Medicine and Urgent Care Clinic (and its affiliated physicians and staff, agents, and officers) shall not be responsible for any personal injury including death, and/or privacy breach (outside the control of Family Medicine and Urgent Care Clinic or its affiliated physicians) or other damages because of my choice to communicate with Family Medicine and Urgent Care Clinic by email. I release Family Medicine and Urgent Care Clinic (and its affiliated physicians, staff, agents, and officers) from any liability relating to communicating with me by email.
I have asked any questions I may have had about this form to Family Medicine and Urgent Care Clinic 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 have either sought that advice or chosen not to seek such advice.

E Mail :

Date :

Name* :

Phone* :

Signature*

Zero Tolerance - Abusive or Aggressive Behavior

At Family Medicine & Urgent Care Clinic, our doctors and staff are concerned about your health and well-being, and it is important that they are treated with respect and courtesy.

Our clinic has a zero-tolerance policy on abusive speech, rudeness, harassment, or aggression of any kind toward doctors and staff members. This means that aggressive or violent behavior towards our doctors and staff member within our practice will not be tolerated under any circumstances either IN PERSON or OVER THE TELEPHONE

A person who causes or threatens to cause any of those behaviors is subject to a warning letter from our clinic Manager to inform such behavior will not be tolerated. Any further violation will result in immediate termination as a client of the Clinic.

We feel sure that you will understand that proper behavior is necessary for our doctors and staff and that non-observance will not be accepted.

Management

Family Medicine & Urgent Care Clinic

Patient Signature*

Date :