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://drive.google.com/file/d/1buImbaK02cSy5RCIuR3b6pBNfyepBFx1/view?usp=sharing
If you prefer, you can print the form and call the clinic to determine how best to provide the completed form.
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.