Consent form

Consent to Use Virtual Care Tools

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

Physician information

Physician: Dr. S. Rasyidah A. Halim
Clinic: 207-8250 Lawson Road, Milton ON, L9T 5C6
Phone: 519-900-7979
Email: info@mindhealth.one

The physician has offered to provide the following means of virtual care. Untick any you do not wish to consent to:

EmailText Messaging (SMS or Whatsapp)Phone callVideoconferencing (Rocket Doctor or Google Meet)

Patient acknowledgment and agreement

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected Services more fully described in the Appendix below. I understand and accept the risks associated with the use of the Services when interacting with the Physician and the Physician's staff. I consent to the conditions and will follow the instructions outlined in the Appendix, as well as any other conditions that the Physician may impose.

I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for virtual care tools, it is possible that interacting with the Physician or the Physician's staff using the Services may not be encrypted. Despite this, I agree to interact with the Physician or the Physician's staff using these Services with a full understanding of the risk.

I acknowledge that either I or the Physician may, at any time, withdraw the option of using the Services upon providing written notice.

Full patient name *

Date of birth *

Home address *

Mobile phone *

Email *

Patient initials *

Appendix — risks, conditions & instructions

Risks of using virtual care tools

Use of virtual care tools to discuss sensitive information can increase the risk of interception by third parties.
Despite reasonable efforts, it is not possible to completely secure information communicated through virtual care platforms.
Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
Virtual care tools can introduce malware into a computer system and potentially damage or disrupt the computer, networks, and security settings.
Communications can be forwarded, intercepted, circulated, stored, or even changed without knowledge or permission.
Even after deletion, backup copies of electronic communications may exist on a computer system.
Communications may be disclosed in accordance with a duty to report or a court order.
Some videoconferencing platforms may be more open to interception than other forms of videoconferencing.

Additional risks if email or text is used

Email and text messages can more easily be misdirected to unintended recipients.
Email, text, and instant messages are easier to falsify than handwritten or signed hard copies; sender identity and recipient-only access cannot be guaranteed.

Conditions of using the Services

The Physician cannot guarantee that all electronic communications will be reviewed and responded to within a specific time. The Services will not be used for medical emergencies or time-sensitive matters.
If a response is expected and not received in a reasonable time, it is your responsibility to follow up.
Virtual care is not a substitute for in-person or telephone communication, clinical examinations, or attending the Emergency Department when needed.
You are responsible for scheduling appointments where warranted.
Electronic communications or recordings may be included in your medical record and accessible to authorized staff.
The Physician will not forward communications to third parties, including family members, without prior written consent, except as authorized or required by law.
You agree to inform the Physician of any information you do not want sent via virtual services.
Some Services may be limited to educational, informational, or administrative purposes only.
The Physician is not responsible for information loss due to technical failures of your software or internet service provider.

Instructions for using the Services

Reasonably limit or avoid using an employer's or other third party's computer.
Conduct virtual care encounters in a private setting and using a secure device, where possible.
Obtain the Physician's consent prior to making any recording of the virtual care encounter.
Inform the Physician of any changes in email address, mobile phone number, or other account information.

If Services include email and/or text

Include an appropriate subject line (e.g. "prescription renewal") and your full name in the body of the message.
Review all electronic communications for clarity and completeness before sending.
Take precautions such as using screen savers and safeguarding computer passwords.
Withdraw consent only by email or written communication to the Physician.
If you require immediate assistance or your condition is serious or rapidly worsening, do not rely on the Services — call the office, go to the nearest Emergency Department, or call 9-1-1.

Please confirm to sign

I have read and fully understand the risks, limitations, conditions of use and instructions for use of the selected Services as described above.I understand that communications using these Services may not be encrypted and I agree to accept this risk.I have reviewed and understand all of the risks, conditions, and instructions described in the Appendix.

Electronic signature

By signing below, I confirm the above consent and acknowledge 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 *