Consent form

Consent to Use AI Medical Scribe

Please read the information below carefully, acknowledge each statement, and sign electronically at the bottom. A copy of your signed consent will be sent to the clinic.

Renewal required every 1 year

Clinic information

Physician: Dr. S. Rasyidah A. Halim
Clinic: 8250 Lawson Road, Milton ON, L9T 5C6
Phone: 519-900-7979
Email: info@mindhealth.one

About Scribeberry

Scribeberry is a HIPAA- and PIPEDA-compliant application powered by an AI language model. It assists healthcare professionals with data collection and note-taking, generating clinical notes and letters that support patient care. It can process information in text, audio, and live conversation form, and may involve an Autonomous Doctor Assistant (ADA) that is used strictly for note-taking and collection of health information by your healthcare provider.

You can review Scribeberry's own patient FAQ at scribeberry.com/resources/faq.

Purpose of use

Dr. Siti Rasyidah Abd Halim uses Scribeberry to improve the efficiency and accuracy of medical documentation, freeing more time to focus on your care during the visit.

How Scribeberry works

Scribeberry securely processes the conversation during your appointment to prepare a draft clinical note.
It does not diagnose conditions, recommend treatment, or make clinical decisions.
Dr. Halim reviews, edits as necessary, and approves every note before it becomes part of your medical record.
AI-generated notes may contain errors and are never relied upon without physician review.

Data processing, confidentiality and security

Scribeberry may process sensitive health information provided during your consultation. All data is transferred over encrypted channels, and requests and responses between the application and the AI model are encrypted end-to-end. Information processed through Scribeberry is used solely to support your ongoing clinical care and documentation.

No personal health data submitted through Scribeberry is used to train or improve any AI model, whether third-party or self-hosted. Scribeberry has submitted a Privacy Impact Assessment (PIA) to the Office of the Information and Privacy Commissioner in Alberta.

Third-party technologies

Depending on provider location, content-filtering policy and data-storage requirements, Scribeberry may use Microsoft Azure's OpenAI service and/or Anthropic's Claude in a manner compliant with PHIPA, PIPEDA, applicable provincial Canadian regulations, and HIPAA. Scribeberry maintains Business Associate Agreements (BAAs) with Microsoft Azure and Anthropic to protect your privacy. No data is shared directly with OpenAI.

Privacy in Ontario (PHIPA)

Your personal health information is collected, used, disclosed and safeguarded in accordance with Ontario's Personal Health Information Protection Act, 2004 (PHIPA). It is not used for advertising.

Potential risks

While Scribeberry is designed to improve the efficiency of your care, there are potential risks associated with its use, including inadvertent errors in transcription or interpretation of your health information and — although highly unlikely — breaches of data security. Rigorous protocols are in place to manage these risks. A more detailed Notice of Privacy Practices is available from the clinic on request.

Your choice

You may ask questions at any time and are encouraged to discuss any concerns with your healthcare provider before signing. You may decline or withdraw consent at any time before or during your appointment, without affecting the quality or provision of your care. If you decline, your appointment will be documented using traditional methods.

Patient information

Full patient name *

Date of birth *

Email *

Patient initials *

Patient acknowledgment

Consent

I consent to the use of Scribeberry during my appointments.

Please confirm each statement below if you consent to the use of Scribeberry:

I understand the purpose of Scribeberry AI Medical Scribe.I understand Dr. Halim remains responsible for all documentation and clinical decisions.I understand my information will be handled in accordance with PHIPA (Personal Health Information Protection Act, 2004).I understand I may refuse or withdraw consent without affecting my care.

Do not Consent

I do not consent to the use of Scribeberry during my appointments.If ticked, you do not need to confirm the statements above or provide an electronic signature.

Electronic signature

By signing below, I understand that this electronic signature has the same legal effect as a handwritten signature.

Patient signature *

Sign above using your finger, stylus or mouse.

Signed by (typed name) *

Date *