Consent to Use Electronic Communications
This form was adapted from the CMPA Consent for Electronic Communications Form, which can be found here: https://tinyurl.com/cmpae-consent

A paper version of this form can be printed here: https://tinyurl.com/ffpe-con

If you prefer, you can print the form and call the clinic to determine how best to provide the completed form.
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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 electronic communication Services more fully described in the Appendix to this consent form. I understand and accept the risks outlined in the Appendix to this consent form, associated with the use of the Services in communications 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 on communications with patients using the Services.

I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the Physician or the Physician’s staff using the Services may not be encrypted. Despite this, I agree to communicate 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 communicating electronically through the Services upon providing written notice. Any questions I had have been answered.
Do you consent to video appointments with our physicians? Since the onset of the COVID-19 pandemic, we are booking mostly video and telephone visits with patients first, before offering in-person appointments. We likely will continue to offer telehealth appointments after COVID-19. *
Required
Do you consent to be contacted by our office via text messages (SMS)? This could include appointment reminders, and using SMS to check in to our office when you arrive. *
Required
Do you consent to be contacted by our office via email? This could include receiving laboratory and imaging requisitions, specialist appointment information. *
Required
Would you like to be set up to use our Patient Portal (either app or website)? This will enable you to to book your own appointments, and see your medical record, among other things. If you select yes, our office will contact you about setting up your access in 5-15 business days. *
Required
Your First Name *
Your Last Name *
Date of Birth *
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Preferred Email Address *
Preferred Mobile Phone Number *
Your family doctor
Are you completing this form on behalf of a child under the age of 16?
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