Consent- Out of Country Visitors and Residents
Full Legal Name *
Preferred name *
Gender: *
Date of Birth: *
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Home/International Address
Street: *
City: *
Postal/ZIP Code *
Province/State *
Country *
Local Address
Accommodation & Room # (or street) *
City: *
Postal/ZIP *
Province/State *
Country *
Best Contact Phone Number: *
Home/Cell Number: *
Email Address: *
Emergency Contact Name: *
Relationship: *
Emergency Contact Phone Number: *
Whistler Employment (if applicable):
PHN (Personal Health Number -MSP of BC if applicable)
Drug Allergies: *
Governing Law Jurisdiction Agreement
I hereby agree that:
A) All aspects of the relationship between me and the WHISTLER MEDICAL CLINIC (as well as her/his agents, delegates, employees, and any physicians and other independent health care practitioners providing medical or other health care and treatment to me, or in association with the Whistler Medical Clinic), including without limitation any medical or other healthcare and treatment provided to me and

B) The resolution of any and all disputes arising from or in connection with that relationship, including any disputes arising under or in connection with this Agreement, shall be governed by and construed in accordance with the laws of the Province of British Columbia and the laws of Canada applicable therein.

Jurisdiction

I hereby acknowledge that the medical or other health care and treatment I receive from the WHISTLER MEDICAL CLINIC will be provided in the Province of British Columbia, and that the Courts of the Province of British Columbia shall have exclusive jurisdiction to hear any complaint, demand, claim, proceeding or cause of action, whatsoever arising from or in connection with that medical or other health care and treatment, or any other aspect of my relationship to the WHISTLER MEDICAL CLINIC.

Release of Information

I hereby authorize Whistler Medical Clinic to release any pertinent information in my patient file to my insurance company and/or my family physician.
Signature of Patient (or Guardian): *
Date: *
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