STUDENT WELLNESS SERVICES (SWS)
STUDENT EMAIL CONSENT FORM
*
Student's Name:
*
Student's Date of Birth:
*
Queen's Email:
1.
RISK
OF USING EMAIL
Risks to consider include but are not limited to:
a)
Email can be circulated, forwarded, stored, printed,
and broadcast to unintended recipients.
b)
Email senders can misaddress an email.
c)
Backup copies of email may exist even after the
sender or the recipient has deleted his or her copy.
d)
Queen's University has the right to
inspect
email transmitted
through their systems.
e)
Email can be intercepted, altered, forwarded, or
used without
authorization or detec
tion.
f)
Email can be used to introduce viruses
4.
STUDENT ACKNOWLEDGMENT AND AGREEMENT
- I understand the risks associated with the
communication of email between SWS and me.
- I understand that if I initiate contact by email, SWS
may take that as consent to reply by email to the
content of my email.
- I understand that I can choose to consent to email as a
means of contact for SWS.
- I understand the conditions and instructions outlined
here, and accept that SWS may impose other
instructions related to communicating with me by email.
- I agree to use only the pre-designated email address
specified above.
- I understand that in using Student Wellness Services,
I acknowledge that I have read, understand and accept
the practices described above.
*
Student Signature ____________________________
*
Date
_______________________________________
3.
CONDITIONS FOR THE USE OF EMAIL
SWS cannot guarantee but will use reasonable means
to
maintain security and confidentiality of email information
sent and received. The Student and SWS must consent
to the following conditions:
a)
Email is
not appropriate for urgent or emergency
situations. The Provider cannot guarantee that any
particular email will be read or responded to.
b)
Email must be concise. The Student should schedule
an
appointment to discuss the details of an issue.
c)
Email communications will be filed in the Student’s
permanent health record or departmental
file.
d)
Emails may also be delegated to another provider
or
staff member for response. Office staff may also
receive and read or respond to patient messages.
e)
E
mails sent by students will not be forwarded
outside
of
SWS without the Student’s prior written
consent, except as
authorized or required by law.
f)
Email shoud not be used for communication
regarding details of m
edical or health conditions.
g)
It is the Student’s responsibility to follow up
and /or schedule an appointment if warranted.
Revised
0
5/18
h) Medical / health advice will not be provided by email
i) SWS is not responsible for technical failures which
may preclude receipt of your emails.
* Student Number:_______________________________
*
Witness Signature___________________________
*
Date_______________________________________
5.
AUTOMATED EMAILS
SWS sends automated emails to remind students of
appointments. The automated reminders contain
information about the date and time of the student's
appointment at SWS. SWS may also send emails
with a link to provide feedback on SWS services.
These automated emails do not contain any
information about the appointment or nature of
service received.
_____(Initials) I give consent for SWS to use email as
a means of contact with me.
EMAIL COMMUNICATION
Student Wellness Services uses email to communicate
information that may be of a sensitive nature to
students. This includes information about appointment
bookings, rescheduling appointments, invoices, referral
updates, test result follow-ups, and other similar
information.
2.
_____(Initials) I do not give consent for SWS to use
email as a means of contact with me. I understand
this means I will not receive appointment reminders.
*
*
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