I hereby confirm that the above information is true and correct and that the
Personal Health Number is current and valid.
By supplying my home/cell phone number, email address and any other personal
information, I authorize South Surrey Medical Clinic to use my personal
information to contact me with respect to appointment times, referral notices
(including Pathways electronic communications), result information,
appointment reminders, and other limited information. I also consent to South
Surrey Medical Clinic sharing my personal information, including health
information, electronically with specialists / consultants and specialty
clinics and their staff, including to communicate through Pathways. Pathways
is an online resource that allows referring physicians and their office staff
to quickly access current and accurate referral information, including wait
times and areas of expertise, for specialists / consultants and specialty
clinics and their staff. Pathways helps physicians to send and track
referrals, helps specialists to track referrals, and allows specialists and
referring physicians to communicate with each other, notify patients of their
upcoming appointments and appointment changes, and send reminders to patients.
I am also aware it is my responsibility to keep my contact information
I acknowledge that I am responsible for the payment of all charges for any
treatment that may not be paid or covered by my Medical Services Plan, ie.
Insurance forms, driver's physicals, sick notes, employment and sports
physicals and transfer of records.
I hereby acknowledge that the medical or other healthcare treatment received
by myself from South Surrey Medical Clinic and any of its physicians will be
provided in the province or territory of British Columbia, and that courts of
British Columbia all have the exclusive jurisdiction to hear any complaint,
demand, claim, proceeding or cause of action, whatsoever arising from or in
connection with that medical or other healthcare and treatment, or from any
other aspect of the relationship between the physician and myself.
I also agree that 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 accordance with the laws of
the province or territory of British Columbia (other than conflict of laws
rules) and the laws of Canada applicable therein.
I authorize this medical practice to access my health information recorded
elsewhere – including Pharmanet Medication Profile – for the purpose of
providing care and treatment. This consent will continue until I revoke it in
writing. I have been provided with sufficient time to review this consent form
and any questions I had have been answered. I understand that I may ask
additional questions at any time.
By checking I agree, I consent my physicians and his or her office staff to
communicate certain types of personal and/or health information electronically
to : (a) me; and (b) other physicians and their office staff. I agree I have
read, understood and accepted the conditions in Appendix A.
Appendix A - 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
and Pathways cannot guarantee the security and confidentiality of electronic
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
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.
Videoconferencing using services such as Skype or FaceTime may be more open
to interception than other forms of videoconferencing.
Email, text messages, and instant messages can more easily be misdirected,
resulting in increased risk of being received by unintended and unknown
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
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
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
Inform the Physician of any changes in the patient's email address, mobile
phone number, or other account information necessary to communicate via the
Review all electronic communications to ensure they are clear and that all
relevant information is provided before sending to the physician.
Take precautions to preserve the confidentiality of electronic
communications, such as using screen savers and safeguarding computer
Withdraw consent only by phone email or written communication to the
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
(A copy of these terms along with Appendix A – Risks of using electronic communication will be emailed to you. Please let us know if you wish to withdraw the right to contact use via email or text by making our front staff aware either verbally or in written or email communication).