Town Plaza Medical Clinic
#40 4314 Main Street
Whistler, BC
Email Address *
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.

PLEASE NOTE: APPENDIX - 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 of 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 maybe disclosed in accordance with a duty to report or a court order.
• Videoconferencing using services such as, Skype or FaceTime may be more open to interception than other forms of videoconferencing.

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.

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 and billing personnel, may have access to those communications.
• The Physician may forward electronic communications 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: Sexually transmitted disease, AIDS/HIV, Mental health, Developmental disability, Substance abuse
• 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.

Instructions for communication using the Services:

To communicate using the Services, you must:

• Reasonably limit or avoid using 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 the Services include email, instant messaging and/or text messaging, the following applies:

• Include in the message’s subject line an appropriate description of the nature of the communication (e.g. “prescription renewal”), and your full name in the body of the message.
• Review all electronic communications to ensure theyare clear and that all relevant information is provided before sending to the physician.
• Ensure the Physician is aware when you receive an electronic communication from the Physician, such as by a reply message or allowing “read receipts” to be sent.
• Take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.
• Withdraw consent only by email or written communication to the Physician.
• 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.

I agree that any dispute arriving from the telemedicine consult will be resolved in the Province of British Columbia.
Telehealth visit is an MSP-insured benefit. I understand that a fee of $100 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 hereby authorize the Physicians of Town Plaza Medical Clinic (4314 Main Street, Whistler, BC) to use electronic communication in the course of my diagnosis and treatment.

Governing Law and Jurisdiction Agreement

Governing Law

I hereby agree that :

a) all aspects of the relationship between me and Richard Tamplin/Janice Carr/Town Plaza Medical Clinic (as well as his/her/the 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 Richard Tamplin/Janice Carr/Town Plaza Medical Clinic), including without limitation any medical or other health care 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.


I hereby acknowledge that the medical or other health care and treatment I receive from Richard Tamplin/Janice Carr/Town Plaza 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 from any other aspect of my relationship to Richard Tamplin/Janice Carr/Town Plaza Medical Clinic.

Please have the patient or his/her legal representative type his/her full name as an electronic signature.
Patient's First Name: *
Patient's Last Name: *
Patient Date of Birth: *
Patient or Patient Representative Signature (please type your full name): *
Date: *
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