Dr. Bream & Associates

Welcome to our clinic. We are pleased to offer the online form to our patients in order to reduce the waiting times and the exposure in a public setting.

The information provided is strictly confidential.

Please fill out this application completely to the best of your ability.

A copy will be sent to your email address given in this form.

Thank you
EYETELLIGENCE Team

 

PATIENT PROFILE

PATIENT ELECTRONIC COMMUNICATION CONSENT

Electronic communication is a widely accepted form of communication. While it cannot replace personal encounters between you and your health care provider, it can be a convenient way to exchange information.

All electronic communication will be acknowledged in a timely fashion. However, we do not monitor when the office is closed for weekends, evenings, statutory holidays and during vacations. Please consider our office hours when you are waiting for a reply to your electronic communication. As a general rule, we will respond to patient emails within 3 business days. If you do not receive a response within the designated time period, please assume that your email was not received and call the office to follow up.

If you are experiencing a medical emergency call 911 IMMEDIATELY.

Contact Information:
If at any time you wish to opt out of electronic communications kindly contact our office.
Withdraw consent only by email or written communication to the Physician (clinic@drbream.com)

Our commitment to you:

• Dr. Bream & Associates and Eyetelligence (from here on called “we”) are committed to following the privacy and security guidelines as mandated by law in the PHIPA (2004) and Bill C-28 and Bill C-29 Amendments to PIPEDA.

• All forms of personal information shared with your health care team are kept in confidence and used solely for the provision of your health care.

• Dr. Bream & Associates and Eyetelligence will not release any contact information (address, phone, or email) to a third party unless it is directly related to the provision of your health care or mandated by law.

• When providing general information to more than one electronic communication recipient at the same time, we will protect your privacy by sending the message using blind copies (BCC).

Do NOT use email for any of the following

► As a substitute for an appointment with your health care provider.

► Requesting a diagnosis based on a written description of symptoms.

► Any frivolous, commercial, or unapproved purpose.

ACKNOWLEDGEMENT AND CONSENT

I understand and agree that:

• Electronic communication is not an appropriate substitute for clinical examinations. I am responsible for following up on the physician’s electronic communication and for scheduling appointments where warranted.

• Electronic communication is not to be used in emergencies, or when I need information or advice urgently.

• Electronic communication may be accessed by medical office staff in the course of their duties.

• Electronic communication may be accessed by my health care provider’s medical colleagues while caring for me when my health care provider is absent.

• Electronic communication will use respectful language.

• I will not send pictures via electronic communication unless I have been asked by my physician to do so.

• Electronic communication will not be used for frivolous or commercial purposes. Or any purpose outside the context of my direct patient-health care provider relationship.

• Electronic communication between me and this medical practice will become part of my confidential patient record.

• This medical practice may use electronic communication to send me prescription, invoice, drug alerts, appointment reminders, health promotion material and other educational resources.

• Electronic communication is a privilege that may be withdrawn at the discretion of this medical practice.

• Electronic communication is only for the residents of Ontario and is governed by the laws of the Province of Ontario.

• Electronic communication 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 electronic communication once it has been sent.

• Electronic communication can introduce viruses into a computer system and potentially damage or disrupt the computer.

• Electronic communication can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the physician or patient. Electronic communication senders can easily misaddress an email, resulting in it being sent to many unintended and unknown recipients. Electronic communication is indelible. Even after the sender and recipient have deleted their copies of the email, backup copies may exist on a computer or cyberspace.

• Use of electronic communication to discuss sensitive information can increase the risk of such information being disclosed to third parties.

• Emails may be forwarded internally to staff and to those involved, as necessary, for diagnosis, treatment, reimbursement, or health care operations.

• Dr. Bream & Associates and Eyetelligence are not responsible for information loss due to technical failures.

• Dr. Bream & Associates and Eyetelligence may use Videoconferencing for any virtual consultation. Using services such as Skype, Teams, Zoom, WebX or FaceTime may be more open to interception than other forms of telemedicine.

• I understand the need to take precautions to protect privacy and the confidentiality of my medical information and the appropriate behaviour during the video/audio conference with my care providers.

• I agree and acknowledge there may be circumstances during a telemedicine event when the use of patient photography, videotaping, and other visual and/or audio recordings would be deemed beneficial by a consulting health care professional.

• I will notify the Dr. Bream & Associates and Eyetelligence of any changes to my electronic communication address.

• I acknowledge Dr. Bream & Associates and Eyetelligence right to, upon provision of written or electronic communication notice, withdraw the option of communicating through email.

• I will not add the Dr. Bream & Associates and Eyetelligence electronic communication address to any group mailing list.

I have read and understood the Electronic Communication Consent Form and fully acknowledge that sending personal health information via electronic communication is not secure and I fully accept the risks and responsibility involved with this.

I hereby waive any and all claims against the Physicians and Staff at Dr. Bream & Associates and Eyetelligence Inc. in connection with the disclosure of my personal health information via email.