Consent To Use Electronic Communications (Page 3 of 3) in pdf

Consent To Use Electronic Communications Page 3

APPENDIX

CONTINUED

• Ensure the Physician is aware when you receive an electronic

Instructions for communication using the Services

To communicate using the Services, you must:

communication from the Physician, such as by a reply

message or allowing “read receipts” to be sent.

• Reasonably limit or avoid using an employer’s or other third

party’s computer.

• Take precautions to preserve the confidentiality of electronic

communications, such as using screen savers and

• Inform the Physician of any changes in the patient’s email

safeguarding computer passwords.

address, mobile phone number, or other account information

• Withdraw consent only by email or written communication to

necessary to communicate via the Services.

the Physician.

• If you require immediate assistance, or if your condition

If the Services include email, instant messaging and/or

appears serious or rapidly worsens, you should not rely on

text messaging, the following applies:

the Services. Rather, you should call the Physician’s office or

• Include in the message’s subject line an appropriate description

take other measures as appropriate, such as going to the

of the nature of the communication (e.g. “prescription

nearest Emergency Department or urgent care clinic.

renewal”), and your full name in the body of the message.

• Other conditions of use in addition to those set out above:

• Review all electronic communications to ensure they are clear

(patient to initial)

and that all relevant information is provided before sending to

the physician.

I have reviewed and understand all of the risks, conditions, and instructions described in this Appendix.

Patient signature

Date

Patient initials______

Consent To Use Electronic Communications Page 3