FORM3: Patient Consent for Collaborative Care

Dr. Bream & Associates

FORM3: Patient Consent For Collaborative Care

Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA)

e.g.: Colloborate with your Family Physician, Specialist or your Pharmacist
We are pleased to offer this service to our patients in order to reduce the waiting times and the exposure in a public setting. The information provided is strictly confidential.

Thank you
EYETELLIGENCE Team

ACKNOWLEDGEMENT
At Eyetelligence, we embrace collaborative care to improve the patient experience, deliver better health outcomes and to prevent medication errors. Our Physicians will update your Family physician, Specialist or any related care provider with a summary of your Ocular health. I, {nameas}, authorize my Optometrist to collaborate or disclose my Ocular health information with the below care providers. I understand that I can refuse to sign this consent form. Care providers:

Family PhysicianSpecialistsPharmacistHospitals
Full Name*
Patient or Substitute Decision Maker
Signature Date*

MonthDayYear
Signature*

Clear
Should be Empty: