New Patient Registration Form – Continued
any specific period of time. The Services will not be used
for medical emergencies or other time-sensitive matters.
If your electronic communication requires or invites a
response from the 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
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 Physician may forward electronic communications
to staff and those involved in the delivery and
administration of your care. The Physician might use one
or more of the Services to communicate with those
involved in your care. The Physician will not forward
electronic communications to third parties, including
family members, without your prior written consent,
except as authorized or required by law.
• You agree to inform the Physician of any types of
information you do not want sent via the Services, in
addition to those set out above. You can add to or modify
the above list at any time by notifying the Physician in
writing.
• Some Services might not be used for therapeutic
purposes or to communicate clinical information. Where
applicable, the use of these Services will be limited to
education, information, and administrative purposes.
• The Physician is not responsible for information loss due
to technical failures associated with your software or
internet service provider.
Instructions for communication using the Services
To communicate using the Services, you must:
• Reasonably limit or avoid using an employer’s or other
third party’s computer.
• Inform the Physician of any changes in the patient’s
email address, mobile phone number, or other account
information necessary to communicate via the Services.
If the Services include email, instant messaging and/or
text messaging, the following applies:
• 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 physician.
• Ensure the Physician is aware when you receive an
electronic communication from the Physician, 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 Physician.
• If you require immediate assistance, or if your condition
appears serious or rapidly worsens, you should not rely on
the Services. Rather, you should call the Physician’s office
or take other measures as appropriate, such as going to
the nearest Emergency Department or urgent care clinic.
I have reviewed and understand all of the risks, conditions, and instructions described in this
document.
Patient Name: ________________________________________________________
Signature: ____________________________________
Date: ____________________________
Upon Completion of this document, you can either save the document and email it to us, or save the
document and select "submit form" button.
Please SAVE THE FILE before submitting the form.
