Legal Document

Patient Email Consent Form

Before we communicate with you by email, we need your informed consent. Please read the following carefully — it explains how email is used, what its limitations are, and what you're agreeing to.

Your Consent to Email Communication

I,                                                consent to the use of email communication with the staff and physicians at Summerville Family Health Team.

I can expect to receive email from Summerville Family Health Team regarding items such as appointment reminders, instructions for upcoming tests/exams, etc. Summerville Family Health Team will not communicate diagnoses, test results, or transmit other personal health information by email that will require a follow-up visit to Summerville Family Health office. Email communication is not a substitute for a clinical assessment and the best way to share information with your health care provider is in person.

What You Should Know About Email Privacy

I am aware of the following:

  • There are some privacy risks in communicating by email.

  • Email is not considered a secure method of communicating with us. Email messages may not be encrypted on the Summerville Family Health Team email system. Emails can be intercepted and we cannot guarantee the security and confidentiality of any email communications that you send to or receive from us.

  • Emails may be filed on your health record depending on the content of the email message and can become a permanent part of your health record. As they can become part of your health care record, they may be shared within the Summerville Family Health Team or third parties if permitted or required by law (including other health care providers and OHIP for example). Email can also be used as evidence in a court or law.

  • Email is easy to forge, easy to forward (sometimes accidentally) and may exist indefinitely.

  • Emails can introduce viruses into a computer system, and potentially damage or disrupt the computer.

  • Summerville Family Health Team is not responsible for information loss due to technical failures.

  • I will be expected to notify Summerville Family Health Team in writing should I no longer wish to receive email communications.

Emergencies & Appointment Scheduling

Email should not be used to communicate emergencies or time-sensitive health care issues. If you are experiencing an emergency, you should call 911 or go to a hospital or health care provider immediately.

Appointments with Summerville are to be made by telephone for all regular non urgent consultations. See our Contact & Hours page for telephone information. We do not have a 24-hours per day/7-days per week monitoring of incoming email messages and cannot guarantee a particular response time for an email. It is your responsibility to follow up by telephone if you require a response to an email message.

It is your responsibility to keep your email address up-to-date with our office and notify us of any changes. We do not recommend that you use a shared email address for purposes of communicating with us, as there may be some information that you do not wish to share with others. Please be advised that if you choose to use a work email address, that your employer may have the legal right to inspect and keep emails that pass through their system. There may be information that you do not wish to share with your employer.

Patient Acknowledgement, Agreement & Release

  • I acknowledge that I have read and fully understand this consent and release form.

  • I understand the risks and limits associated with communicating with Summerville Family Health Team by email and I accept those risks and limits.

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

  • I have asked any questions I may have had about this form to Summerville Family Health Team and agree that my questions have been answered.

  • I understand I have the right to have legal advice about signing this form and what it means to me and have either sought that advice or chosen not to seek such advice.

Your Signature & Details

Complete all fields below and print or bring this form to our office. By signing, you confirm that you have read and agree to all terms above.

Enter your full legal name
your@email.com

This is the address we will use to contact you.

Sign here

Your signature confirms your agreement to all terms above.

DD / MM / YYYY
DD / MM / YY
Print your full name clearly

To submit this consent form, please print this page and bring the completed, signed form to our office, or contact us directly:

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Your information is handled in accordance with our Privacy Policy.

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