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Email Consent Request

Please review the following email policy and submit consent below.

Risks of using email

Transmitting patient information poses several risks of which you should be aware. You should not agree to communicate via email without understanding and accepting these risks. The risks include, but are not limited to, the following:

  1. The privacy and security of email communication cannot be guaranteed.
  2. Employers and online services may have a legal right to inspect and keep emails that pass through their system.
  3. Email is easier to falsify than handwritten or signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email once it has been sent.
  4. Emails can introduce viruses into a computer system, and potentially damage or disrupt the computer.
  5. Email can be forwarded, intercepted, circulated, stored or even changed without the knowledge or permission of the EWFHT or the patient. Email senders can easily misaddress an email, resulting in it being sent to many unintended and unknown recipients.
  6. Email may be permanent. Even after the sender and recipient have deleted their copies of the email, back-up copies may exist on a computer or in cyberspace.
  7. Use of email to discuss sensitive information can increase the risk of such information being disclosed to others.
  8. Email can be used as evidence in court.
  9. Choosing not to use encryption software increases the risk of privacy violation.

Conditions of using email

The EWFHT will use reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined above, the security and confidentiality of email communication cannot be guaranteed. Thus, you must consent to the use of email which includes agreement with the following conditions:

  1. Although we will endeavour to read and respond promptly to your email, we cannot guarantee that any particular email will be read and responded to within any particular period of time. Thus, you should not use email for medical emergencies or other time-sensitive matters.
  2. Emails about medical issues may be made part of your medical record and may be seen by staff with authorized access.
  3. We may forward your emails to others involved with your medical care. We will not, however, forward your emails to anyone else without your prior written consent, except as authorized or required by law.
  4. Email communication is not an appropriate substitute for clinical assessments. You are responsible for following up on emails and for scheduling appointments when warranted.
  5. If your email requires or invites a response and you have not received a response within a reasonable time period it is your responsibility to follow up on this.
  6. Email should not be used for sensitive medical information, such as sexually transmitted disease, AIDS/HIV, mental health, developmental disability, or substance abuse.
  7. We are not responsible for information loss due to technical failure.

Instructions for communication by email

  1. Use your own personal computer.
  2. Inform the EWFHT of any changes in your email address.
  3. State your name and the reason for the email in the subject line (e.g., ‘John Smith - prescription renewal’).
  4. Respond to emails that require a response.
  5. Use passwords to secure access to your computer.
  6. Withdraw consent only by email or written communication to the EWFHT.
  7. Should you require immediate assistance, or if your condition appears serious or rapidly worsens, you should not rely on email.

Your Details


Name:
 
Date of Birth:
Parent/Guardian:
Email:
Confirm email:
 
Phone Number:
 
Your provider:
Message:
 

Patient acknowledgment and agreement
By submitting this form I acknowledge that I have read and fully understand the EWFHT consent form. I understand the risks associated with the communication of email between the physician and me, and consent to the conditions outlined herein, as well as any other instructions that the physician may impose to communicate with patients by email. I acknowledge the right of the EWFHT to, upon the provision of written notice, withdraw the option of communicating through email. Any questions I may have had were answered.

I agree that the Family Health Team and their physicians, staff, directors, officers and other agents shall not be responsible for any personal injury including death, and/or privacy breach (outside the reasonable control of the Family Health Team) or other damages as a result of my choice to communicate with the Family Health Team by email and I release the Family Health Team and their physicians, directors, officers and other agents from any liability relating to communicating with me by email. 

Parents/Guardians - for patients under the age of 14
I acknowledge that I have read and agree to these terms on behalf of the above-named patient and wish to communicate with EWFHT for the purposes of their clinical care.