Acqua Medical Centre
CONSENT TO USE ELECTRONIC COMMUNICATIONS

Doxy.me and Email communications

Acqua Medical is excited to offer telemedicine visits via secure two-way video conferencing. Our patients would be able to use their webcam-enabled computers (Firefox or Chrome browsers), iPad/iPhone (iphone app), or Android smartphones (Chrome web browser) to have a video conference with our doctors. We will be sending files through this application as well as through our email address: acquamedical.online@gmail.com.

Pathways

We are also excited to be providing upcoming communication via Pathways. Pathways is an online resource that allows referring physicians and their office staff (“Physicians”) to quickly access current and accurate referral information, including wait times and areas of expertise , for specialists/consultants and specialty clinics and their staff (“Specialists”). It helps our clinic to send and track referrals, helps Specialist to track referrals and allows Specialist and referring Physicians to communicate with each other, notify patients of upcoming appointments and appointment changes, and send reminders to patients. Your Physician and the Specialist have offered to use Pathways to communicate referral information between themselves and their offices using electronic communication.

 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.


By signing below, I am consenting to allow my Physician (and Specialists in case of Pathways) to communicate electronically with me (and between themselves about me) as set out in above.

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Patient Name: *
Patient Address: (Full Address including Postal Code) *
Patient Mobile Phone: *
Patient Email: *
Patient signature: (Type Your Full Name) *
Date *
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Witness signature: (Type Your Full Name) *
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APPENDIX
1. Risks of using electronic communication

The Physician will use reasonable means to protect the security and confidentiality of information sent and received using the Services (“Services” is defined in the attached Consent to use electronic communications).However,because the risks outlined below, the Physician cannot guarantee the security and confidentiality of electronic communications:
Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.
Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information.
Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
Electronic communications can introduce malware into a computer system,and potentially damage or disrupt the computer,networks,and security settings.
Electronic communications can be forwarded, intercepted, circulated,stored,or even changed without the knowledge or permission of the Physician or the patient.
Even after the sender and recipient have deleted copies of electronic communications,back-up copies may exist on a computer system.
Electronic communications may be disclosed in accordance with a duty to report or a court order.

If the email or text is used as an e-communication tool, the following are additional risks:
Email,text messages,and instant messages can more easily be misdirected,resulting in increased risk of being received by unintended and unknown recipients.
Email,text messages,and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.

2. Conditions of using the Services

While the Physician will attempt to review and respond in a timely fashion to your electronic communication, the Physician cannot guarantee that all electronic communications will be reviewed and responded to within 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 may have access to those communications.

The Physician may forward the electronic communication 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 and the Physician will NOT use the services to communicate sensitive medical information about matters specified below [check all that apply]:

Sexually transmitted disease
AIDS/HIV
Mental health
Developmental disability
Substance abuse
Other (specify):  

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.

3. Instructions for communication using the Services  
   
To communicate using the Services, you must:
Reasonably limited use of 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 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.

4. Use of Doxy.me Telemedicine
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future
care or treatment.

I understand that I have the right to inspect all information obtained in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.

I understand that I may choose to make an in-person appointment at any time.

I understand that the doctor may recommend I schedule an in-person appointment to address issues that cannot be adequately addressed through telemedicine.

I understand that telemedicine involves encrypted electronic communication of my personal medical information.

I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

Telehealth visit is an MSP-insured benefit. I understand that a fee of $85 per visit (subject to change) is applicable if I do not have current MSP coverage on the day of the tele-visit. I agree to pay all applicable fees upon receipt of invoice.

I agree that any dispute arriving from the telemedicine consult will be resolved in the Province of British Columbia.

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